
aassIgJk_lM 
Book 



Entry Catalogue Number 

.^<G,.32cl. 

Class 



PRESENTED BY 



0-6 



A SYSTEM OF GYNJICOLOGT 



r'l5^)<^o 



A 



SYSTEM or GYNECOLOGY 



BY MANY WEITEES 



3^2. 



EDITED BY 

THOMAS CLIFFOKD ALLBUTT 

il.A., il.D,, Lli.D., F.R.C.P., F.R.S., F.L.S., F.S.A. 
BEGIUS PEOFESSOE OF PHYSIC IN THE L'XlTEBSrTT OF CAMBRIDGE, 

FELLQ-^T OF GOXVILLE A>'D GAITS COLLEGE 



W. S. PLAYFAIR 



M.D., LL.D., F.R.C.P. 

PROFESSOB OF OBSTETRIC ilEDICTNT: C« KI>'G'S COLLEGE, AND 

OBSTETRIC PHYSICIAX TO KING'S COLLEGE HOSPITAL 



^' 



I 



THE MACMILLAN COMPANY 

LOXDOX: MACMILLAX & CO., Ltd. 

1897 

All rights reserved 






Copyright, 1896, 
By the MACMILLAN COMPANY. 



Set up and electrotyped October, 1896. Reprinted October, 
1897. 

By Transfer 

^0{. 



Novtoooli 53rfSS 

J. S. Cushing & Co. — Berwick St Smith 
Norwood Mass. U.S.A. 



PEEFACE 

In the earlier treatises on medicine diseases of women were included, 
but were of necessity imperfectly described. 

Of late years this department of medicine has grown so largel}' 
that the Editor of the new System of 3fedicine found it would be 
better to deal with it, as a whole, in a volume especially devoted to 
the subject; in the preparation of this volume I have assisted him 
as Joint Editor. 

The advances made Avithin the last few years in Gynaecology are 
perhaps more remarkable than in any other branch of medicine. 

The whole subject is one of recent development. Even the 
work of its pioneers is within the recollection of the older amongst 
us : a treatise on gynaecology written twenty years ago is ab- 
solutely useless as a guide to the practice of to-day, and does not 
contain even a reference to many of the topics now known to be of 
primary importance in connection with diseases of the reproductive 
organs in women; on the other hand, many opinions and methods 
of treatment, then largely taught and practised, have justly pa-ssed 
into oblivion. 

Much of this great progress is undoubtedly on the surgical 
aspect of the subject. The increasing frequency of abdominal 
sections has directed attention to the diseased states thus revealed, 
and to methods of treating them, previously quite unknown. 

Unbalanced zeal has had its inevitable result of injudicious 
practice, which is to be regretted ; against adventure of this 
kind protests have been made by the more conservative minded 



vi SYSTEM OF GYNECOLOGY 

members of our profession, often justly, sometimes unjustly. 
Nor is it in this country alone that this adventurousness is seen. 
Any one familiar with current gynaecological practice, both on the 
Continent and in the United States, must know that the same spirit 
is active there. Indeed, it is probable that gynsecologists abroad 
are apt to impute to their British colleagues a backwardness in 
adopting methods of treatment largely practised by themselves ; 
many of us think, too largely. Conservatism of this sort may have 
its faults, but, on the whole, it is not to be regretted, and it is 
surely better than to err in the opposite direction. 

It is obvious that a collection of independent essays, written by 
men on topics which they have specially studied, must carry more 
weight, and be more useful than any work compiled by a single 
writer. An endeavour has been made to entrust the several subjects to 
thoroughly representative men; and it is hoped that the results of 
their combined labours will give an accurate exposition of gynae- 
cology as it is taught and practised amongst us. 

I am myself alone responsible for the selection of the contributors, 
which my co-editor has left to my judgment; but I am not in any 
way responsible for the opinions they have expressed, — some of 
them, indeed, I do not share. 

In a work by various authors differences of opinion will 
necessarily be found ; some condemn methods of practice which 
others approve and recommend. This does not appear to be 
objectionable ; it is surely better that in vexed and disputed ques- 
tions both sides should be fairly considered. 

W. S. PLAYFAIR. 



CONTENTS 



The Development of Modern Gynecology. M. Handfield-Jones . 
The Anatomy of the Eemale Pelvic Organs. D. Berry Hart 
Malformations of the Genital Organs in Woman. J. William Bal- 

lantyne ...... 

The Etiology of the Diseases of the Female Genital Organs. W 

Balls-Headley ..... 

Diagnosis in Gynaecology. Robert Boxall 
Inflammation of the Uterus. A. H. Freeland Barbour 
The Nervous System in Relation to Gynaecology. W. S. Playfair 
Sterility. Henry Gervis ..... 
Gynecological Therapeutics. Amand Routh 
The Electrical Treatment of Diseases of Women. Robert Milne 

Murray ...... 

Disorders of Menstruation. John Halliday Groom . 

Diseases of the External Genital Organs. William J. Smyly 

Displacements of the Uterus. Alexander Russell Simpson 

Morbid Conditions of the Female Genital Organs resulting from 

Parturition. G«orge Ernest Herman 
Extra-uterine Gestation. John Bland Sutton 
Pelvic Inflammation. Charles James Cullingworth . 
Pelvic Hematocele. William Overend Priestley 
Benign Growths of the Uterus. F. W. N. Haultain 
Hysterectomy. J. Knowsley Thornton . 

vii 



PAGE 

1 

31 



68 

112 
151 

187 
220 
231 
249 

300 
339 
372 
393 

425 
451 
485 
524 
561 
611 



Vlll 



SYSTEM OF GYNECOLOGY 



Malignant Diseases of the UTERrs. W. J. Sinclair 

Plastic Gynecological Operations. John Phillips 

Diseases of the Fallopian Tubes. Alban Doran 

Diseases of the Ovary. W. S. A. Griffith 

Ovariotomy. J. Greig Smith 

Chronic Inversion of the Uterus. Edward Malins 

Diseases of the Female Bladder and Urethra. Henry Morris 



PAGE 

643 
743 
782 
836 
872 
911 
927 



INDICES 



959 



ILLUSTEATIONS 



FIG. 

1. Brim of Bony Pelvis . . . . 

2. Diagram of Bony Pelvis and of Pelvic Floor . 

3. Sagittal Mesial Section of Female Pelvic Floor 

4. Virgin External Genitals with the Labia Majora separated . 

5. Rectal and Vaginal Mucous Membrane 

6. Sphincter Ani in full-time Foetus .... 

7. Axial Transverse Section of right half of Female Pelvic Floor 

8. Axial Transverse Section of Female Pelvic Floor 

9. Axial Coronal Section of right half of Female Pelvis 

10. Blood-supply of Uterus ...... 

11. Lymphatics of Uterus ...... 

12. Lymphatics of Uterus and Pelvis .... 

13. Nerve Diagram ....... 

14. Relations of Uterus and Ovaries viewed through Brim 

15. Sagittal Lateral Section of Female Pelvis 

16. Uterine Mucous Membrane showing relation of Glands and Stroma 

17. Cervix and upper part of Vagina showing Rugae 

18. Seal's Ovary showing Cortical and Medullary Layers 

19. Sagittal Lateral Section of Genital Organs in 3i months' Foetus 

20. Pelvis and Contents from above .... 

21. Perineal Region ....... 

22. Sacral Section of Pelvic Floor ..... 

23. Diagram of Genu-Pectoral Posture showing Vaginal Distension 

24. Dissection from behind ...... 

25. T. S. of Wolffian Bodies in six weeks' Foetus . 

26. T, S. Pelvis, six weeks' Foetus ..... 

ix 



32 
33 
34 
36 

38 
39 
40 
41 
42 
42 
43 
44 
45 
46 
47 
47 
49 
60 
52 
64 
55 
66 
58 
59 



SYSTEM OF GYNECOLOGY 



FIG. 

27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 

43. 
44. 
45. 

46, 

48, 

50. 
51. 
52. 
53. 
54. 
-55. 
■56. 
57. 
58. 
59. 
60. 
61. 
62. 



T. S. of six weeks' Foetus showing Genital Cord 

Section of Ovary and Wolffian Body, Human Embryo, third month 

L. S. of 31 months' Foetus to show development of Hymen . 

Diagram of developing and fully formed Genital Tract 

Anterior View of right Uterine Appendages .... 

Congenital absence of outer two-thirds of right Fallopian Tube 

Uterus Didelphys 

Uterus Bicornis . 

Uterus Septus 

Uterus Unicornis, posterior view 

Atresia Vulvae Superficialis 

Anus Vulval is . 

Pseudo-Hermaphroditism, Perineo-Scrotal Hypospadias 

Female Generative Organs of Halmaturus .... 

Two completely separated Uteri of many Rodentia . 

Single Uterus continued into two separate Cornua of the Insectivora 

Carnivora, Cetacea, and Ungulata .... 
The single Uterus of the Simiae and Man .... 
Section of a Catarrhal Patch on the Vaginal Aspect of the Cervix . 
Healing of a Catarrhal Patch treated by Astringent or Antiseptic Injections 201 
47. Schroeder's operation for excision of the Cervical Mucous Membrane 

in Cervical Catarrh ....... 

49. Section of Tissue removed by Curette from a case of Interstitial 

Endometritis 
Section of the Glands from a case of Glandular Endometritis 
Section of the Uterine Tissue in a case of Chronic Metritis 
Leiter's Coils 
Application of Leiter's Coils 



Bath Speculum . 

Syphon Douche . 

Bed Bath 

Ointment Carrier (Matthews Duncan's) 

Diverging Speculum (Neugebaur's) 

Play fair's Probe 

Uterine Tenaculum Forceps (Sims') 

Intra-Uterine Canula (Atthill's) ; Platinum Canula, with Stilette 

Uterine Scarifier ...... 



60 
60 
61 
62 
70 
71 
75 
76 
78 
79 
92 
94 
104 
114 
114 

114 
114 
196 



202 



208 
208 
214 
257 
258 
258 
259 
260 
263 
263 
264 
264 
265 
266 



ILLUSTRATIONS 



FIG. 

63. 

64. 
65. 
^^. 
67. 



70. 
71. 

72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 



90. 
91. 
92. 
93. 
94. 
95. 
96. 
97. 
98. 
99. 



Steriliser for Instruments (Harrison Cripps') 

Glass Jar for Sponges, Wool-Pads, etc 

Steriliser for Ligatures . 

Catgut or Silk sterilised in Alcoliol 

Junker's Inhaler 

Griffin's Speculum 

Cusco's Speculum 

Gauge Applicator (Whalebone) 

Forceps to introduce Gauge 

Cervical Speculum (Bantock's) 

Duckbill Speculum (Sims') 

Barnes' Tent Introducer 

Chambers' Tent Introducing Forceps 

Uterine Dilator (Hegar's improved) 

Uterine Dilators (Hayes') 

Uterine Dilator (Matthews Duncan's) 

Clover's Crutch . 

Teale's Forceps . 

Budin's Tube 

Graily Hewitt's Uterine Tube . 

Goodell's two Parallel-bladed Dilator 

Uterine Dilator (Ellinger's) 

Sims' Three-bladed Dilator 

Palmer's Two-bladed Dilator . 

Dilator (Priestley's) 

Uterine Dilators (Reid's) 

Scissors, Uterine (Kuchenmeister's) 

Sims' Metrotome 

Simon's Uterine Scoop . 

Sims' Pliable Curette 

Double Uterine Curette (Gervis') 

Eecamier's Curette 

Uterine Scoop, or Spoon Saw (Thomas') 

Dredging Curette (Bell's) 

Uterine Flushing Curette (Auvard's) 

Routh's Flushing Curette 

Vertical Section three months after Curetting 



PAGE 

268 
269 
269 
269 
273 
275 
275 
275 
275 
276 
277 
277 
278 
282 
282 
282 
233 
284 
285 
286 
287 
288 
288 
289 
289 
289 
291 
292 
293 
293 
294 
294 
295 
295 
295 
295 
297 



SYSTEM OF GYNECOLOGY 



PIG. 

100. Vertical Section of the Uterine Mucous Membrane fifty-five days after 

the application of a Caustic 

101. L^clanche Cell . 

102. Carbon Rheostat . 

103. Edelmann Galvanometer 

104. Weston Milliampere Meter 

105. Intra-Uterine Electrode 

106. Apostoli's Carbon Electrode . 

107. Adjustable Platinum Electrode 

108. Electrode for Puncture 

109. Vaginal Electrodes 

110. Portable Battery with Collector and Galvanometer 

111. Spamer's Induction Coil 

112. Sledge Induction Coil .... 

113. Regulator Switch Board for Continuous and Induced Currents 

114. Switch Board for regulating Lighting Currents by means of Re- 

sistances . 

115. Diagram of Switch Board for regulating Lighting Currents by means of 

Shunt 

116. Switch Board for Shunt Regulation 

117. Descent of Perineal Hernia in front of the Broad Ligament 

118. Reposition of the Retro verted Uterus with the Sound 

119. Hodge Pessary in the Vagina retaining the Uterus in situ 

120. Profile on Section of lacerated, but healthy, Cervix Uteri 

121. Profile on Section of lacerated and inflamed Cervix Uteri 

122. Lacerations of Cervix Uteri and Vagina 

123. Laceration of Vagina forming a "Pocket " . 

124. Central Rupture of Perineum 

125. Diagram showing different kinds of Fistula . 

126. Annular sloughing of Cervix Uteri, upper surface 

127. Annular sloughing of Cervix Uteri, lower surface 

128. Slough in one mass of Cervix Uteri, upper part of Vagina, and base of 

Bladder . 

129. Dilated Abdominal Ostium 

130. Gravid Tube . 

131. Tubal Mole in Section . 

132. Microscopical Characters of Chorionic Villi in section, in Blood-clot 



ILLUSTRATIONS 



Xlll 



KIG. PAGE 

133. Diagram to show the early relations of the Amnion and Chorion and the 

Subchorionic Chamber ....... 458 

134. An early Tubal Embryo, showing the Polar Disposition of the Villi . 458 

135. A Gravid Tube with patent Ostium . . . . . .460 

136. Fallopian Tube and Ovary ; Mole and Corpus Luteum from a case of 

complete Tubal Abortion ...... 461 

137. Uterine Decidua ; from a case of Tubal Pregnancy .... 465 

138. Transverse Section of the Pelvis of a Woman with an Embryo and 

Placenta of the fourth month of Gestation occupying the right 

Mesometrium ........ 466 

139. Sagittal Section of a Cadaver, with a Mesometrium Pregnancy at Term . 467 

140. Tubo-Uterine Gestation . . . . . . .470 

141. Injected Uterus with Fibroid ....... 560 

142. Microscopic Section of soft Fibromyoma ..... 567 

143. Microscopic Section of common Fibromyoma .... 568 

144. Section of Fibroid Uterus . . . . . . .569 

145. Diagram of Growth of Uterine Fibroids ..... 570 

146. Encapsulated Submucous Fibroid becoming Polypoidal . . .571 

147. Submucous Polypus ........ 572 

148. Uterus, showing Subperitoneal Fibroids ..... 575 

149. Submucous Intra vaginal Cervical Fibroid ..... 582 

150. Subserous Cervical Fibroid, tilting Uterus above Pubes and bulging 

Posterior Vaginal Wall ....... 582 

151. Advanced Fibrocystic Degeneration of Stalked Subperitoneal Fibroid, 

with partially Twisted Pedicle ..... 587 

152. CEdematous Interstitial Cystic Fibromyoma .... 588 

153. Microphotograph of CEdematous Fibroid, showing Endothelial Lined 

Spaces ......... 589 

154. Complete Kupture of the Perineum and the lower Portion of the Recto- 

Vaginal Septum ....... 746 

155. Relations of Levator Ani to the Rectum and Vaginal Walls ; normal 

Condition ........ 746 

156. Relations of Levator Ani to the Rectum and Vaginal Walls ; injured 

Condition ........ 747 

157. Perineorrhaphy ; preliminary Incisions . . . . . 749 

158. Perineorrhaphy ; Denudation ...... 749 

159. Purse-string Suture ........ 750 



SYSTEM OF GYNECOLOGY 



FIG. PAGE 

160. Perineorrhaphy ; Repair of the Recto-Vaginal Septum . . . 750 

161. Section of torn Sphincter . . . , . . , 750 

162. Perineorrhaphy ; Recto- Vaginal Septum repaired .... 751 

163. „ (Simon-Hegar Method of Suture) . . . .752 

164. ,, ,, ,, ,, 2nd Stage and Side View 753 

165. ,, Alexander Duke^s Method ..... 754 

166. Surface View of Posterior Vaginal Wall with Right and Left Lateral Sulci 755 

167. ,, J, ,, ,, ,, with both Lateral Vaginal Sulci 

sutured ......... 755 

168. Elytrorrhaphy (Sims') . . . . . . .757 

169. Anterior Colporrhaphy ; Denudation and first Layer of continuous Suture 

completed ........ 758 

170. Anterior Colporrhaphy ; Passage of second continuous superimposed 

Suture . . . . . . . . .759 

171. Anterior Colporrhaphy ; Passage of third Layer of superimposed Suture . 759 

172. Lefort's Operation . . . . . . . .760 

173. Colpoperineorrhaphy, first stage ...... 760 

174. ,, ,, second stage ...... 761 

175. ,, ,^ third stage ...... 761 

176. Stoltz's Operation for Cystocele ...... 762 

177. Urethrocele 762 

178. Vaginal Fixation . . . . . . . . 764 

179. Emmet's Scissors (left angular) ...... 766 

180. ,, ,, (angular and curved) ..... 767 

181. Operation for Subinvolution ....... 767 

182. Amputation of Cervix ; Hegar Method ..... 770 

183. ,, ,, Marckwald Method . . . . .770 

184. Vesico- Vaginal Fistula Knives (Sims') ..... 774 

185. Uterine Hook (Emmet's) for making counter pressure . . . 774 

186. Wire Adjuster ......... 774 

187. Mode of freshening the Edges of a Fistula by "Flap-splitting" . . 775 

188. Mode of passing Sutures in Vesico- Vaginal Fistula . . . 775 

189. Mode of applying Counter Pressure to the Point of the Needle by means 

of a Blunt Hook (Emmet's) . . . . . .776 

190. Method of fixing and twisting the Sutures (Sims') .... 777 

191. Juxta-Cervical Fistula (superficial variety) ..... 779 

192. Kolpokleisis 781 



ILLUSTRATIONS 



FIG. 

193. Section of a healthy Tube from a young Subject .... 

194. One of the Plicae in Fig. 193 as seen under a i inch objective 

195. Section, near the Ostium, of an inflamed Tube .... 

196. Section of a Plica, showing the earlier Changes seen in Salpingitis 

197. Section showing the free Surface of the Interior of a Tube which had been 

obstructed and dilated for a long period .... 

198. Section of an inflamed Tube, in its Middle Third, showing active Inflam- 

mation . . . 

199. The free Surface of the Interior of a suppurating Tube 

200. Section of a suppurating Tube, showing advanced Disease 

201. Ovary and Tube, showing Obstruction of the Ostium by a Perimetritic 

Band which forms a Deep Pouch ..... 

202. Tube showing Obstruction of the Ostium from inflammatory Swelling of 

its Coats ......... 

203. Tubes and Uterus from a Patient who died of Phthisis three years after 

Incision of Peritoneum infected with Tubercle 

204. Cystic Fibromyoma of the Fimbriae ...... 

205. Microscopical Section of a Papillomatous Outgrowth from the Left Tube . 

206. Papilloma of the Fallopian Tube ...... 

207. ,, ,, ,, Sections of an outgrowth under high and 

Iovy' Power ........ 

208. Primary Cancer of Fallopian Tube ...... 

209. ,, ,, ,, ,, in Section, with Tubule-like Structure 

210. Dr. Cullingworth's case of Primary Cancer of the Tube . 

211. Dr. Essex Wynter's case of Cancer of the Tube . . . . 

212. Diagram to show placing of Table, Surgeon, Assistants, Nurse, and In- 

struments in Ovariotomy 

213. Tait's Modification of Wells' Catch-Forceps 

214. Catch-Forceps (J. Greig Smith's Model) 

215. Blades of J. Greig Smith's Forceps . 

216. J, Greig Smith's Peritoneal Catch-Forceps 

217. ,, ,, Large Pressure-Forceps 

218. Wells' Large Forceps, bent . 

219. „ ,, ,, straight 

220. , , , , Pressure-Forceps, Rectangular Blades 

221. Thornton's T-shaped Pressure-Forceps 

222. Wells' Clamp-Forceps . 



PAGE 

784 
785 
786 

787 



788 
789 
790 

792 

792 

797 
802 

804 
808 

809 
814 
815 
819 
822 

876 
877 
878 
878 
878 
879 
879 
879 
880 
880 
881 



xvi 



SYSTEM OF GYNECOLOGY 



FIG. PAGE 

223. Nglaton's Cyst-Forceps . . . . . . .881 

224. Sydney Jones' Cyst-Forceps . . . . . . .881 

225. J. Greig Smith's Scissors . . . . . . .882 

226. „ „ Reel Holder . . . . . . .882 

227. Wells' Large Cyst- Trocar 883 

228. Wells' Small Cyst-Trocar with Fitch's Dome . . . .883 

229. Tait's Cyst-Trocar . . . . . . . .883 

230. Sydney Jones' Pedicle Needle ... . . , .884 

231. Wells' Pedicle Needle . . . . . . . .884 

232. J. Greig Smith's Forceps for placing Ligature on Pedicle . . . 884 

233. Keith's Glass Drainage Tube . . . . . . .884 

234. Glass Drainage Tube . . . . . . . .885 

235. Sponge Holder 885 

236. J. Greig Smith's Suture Instrument ...... 885 

237. Tait's Staffordshire Knot 889 

238. Triple interlocking Ligature, Threads inserted, Loops divided . . 890 

239. ,, ,, ,, Threads interlocked ready for tying . 890 

240. „ ,, „ Threads tied . . . . .890 

241. Screw for aiding in the Delivery of Solid Tumours . . . . 895 

242. Aveling's Repositor for producing Elastic Pressure .... 923 



LIST OF AUTHORS 

Ballantyne, John Win., M.D., F.R.C.P., F.R.S. Edin., Lecturer on Midwifery and 
Diseases of Women, Medical College for Women, Edinburgh. 

Balls-Headley, W., M.A., M.D., F.R.C.P., Lecturer on Midwifery and Diseases of 
Women, University of Melbourne, 

Barbour, A. H. Freeland, M.A., B.Sc, M.D., F.R.C.P. Edin., Lecturer on Mid- 
wifery and Diseases of Women, Edinburgh Medical School. 

Boxall, Robert, M.D., M.R.C.P., Assistant-Obstetric Physician and Lecturer on 
Practical Midwifery and Gynaecology, Middlesex Hospital. 

Croom, John Halliday, M.D., F.R.C.P. Edin., Physician to the Royal Infirmary, 
Edinburgh, Clinical Lecturer on Diseases of Women, and Lecturer on Mid- 
wifery and Diseases of Women at the Medical School. 

Cullingworth, Chas. James, M.D., D.C.L., F.R.C.P., Obstetric Physician and 
Lecturer on Midwifery and Diseases of Women, St. Thomas' Hospital. 

Doran, Alban, F.R.C.S. Eng., Surgeon to the Samaritan Free Hospital for Women. 

Gervis, Henry, M.D., F.R.C.P., Consulting Obstetric Physician to St. Thomas' 
Hospital. 

Griffith, Walter, S.A., M.D., F.R.C.P., Assistant-Physician Accoucheur to St. 
Bartholomew's Hospital. 

Handfield-Jones, Montague, M.D., Obstetric Physician and Lecturer on Midwifery 
and Diseases of Women to St. Mary's Hospital. 

Hart, David Berry, M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases of 
Women, Edinburgh Medical School. 

Haultain, F. W. N., M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases 
of Women, Edinburgh Medical School. 

Herman, Geo. Ernest, M.B., F.R.C.P., Senior Obstetric Physician and Lecturer on 
Midwifery to the London Hospital. 

Malins, Edward, M.D., M.R.C.P., Obstetric Physician to the Birmingham General 
Hospital, Professor of Midwifery at Mason College. 

Morris, Henry, M.A., M.B., F.R.C.S., Surgeon to the Middlesex Hospital. 



SYSTEM OF GYNAECOLOGY 



Murray, Robt. Milne, M.A., M.B., F.R.C.P. Edin., F.E.S.E., Lecturer on Mid- 
wifery and Diseases of Women, Edinburgh Medical School, 

Phillips, John, M.A., M.D., E.R.C.P., Assistant Obstetric Physician to King's 
College Hospital. 

Playfair, W. S., M.D., LL.D., F.R.C.P., Professor of Obstetric Medicine in King's 
College, and Obstetric Physician to King's College Hospital. 

Priestley, Sir W. Overend, M.P., M.D., LL.D., F.R.C.P., Consulting Obstetric 
Physician to King's College Hospital. 

Routh, Amand J., M.D., B.S., M.R.C.P., Obstetric Physician to out-patients to 
Charing Cross Hospital, Physician to Samaritan Free Hospital for Women. 

Simpson, Alex. Russell, M.D., F.R.C.P. Edin., Professor of Midwifery, University 
of Edinburgh. 

Sinclair, W. Japp, M.A., M.D., M.R.C.P., Professor of Obstetrics and Gynaecology, 
Owens College, Victoria University. 

Smith, Jas. Greig, M.A., M.B., F.R.S. Edin., Professor of Surgery, University 
College, Bristol. 

Smyly, Wm. J., M.D., F.R.C.P. Ireland, Master of the Rotunda Hospital, Dublin. 

Sutton, John Bland, F.R.C.S., Assistant Surgeon to the Middlesex Hospital, Sur- 
geon to the Chelsea Hospital for Women. 

Thornton, J. Knowsley, M.B., CM., Consulting Surgeon to the Samaritan Free 
Hospital. 



In order to avoid frequent interruption of the text, the Editor has only inserted 
the numbers indicative of items in the lists of "References" in cases of emphasis, 
where two or more references to one author are in the list, where an author is quoted 
from a work published under another name, or where an authoritative statement is 
made without mention of the author's name. In ordinary cases an author's name is 
a sufficient indication of the corresponding item in the list. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 

Great as the progress has been during the last fifty years in every 
domain. of medicine, in no department has it been so marked as in that 
which embraces the diseases peculiar to women. Indeed, in tracing the 
developments of modern gynaecology, it is difficult for the student of our 
times to estimate the value of each claim to progress, and to set a just 
price on each alleged advance ; for it must be allowed that among many 
brilliant achievements many false starts have been made, and the boasted 
triumph of yesterday has been ranked among the failures of to-day. 

Sir William Priestley, in his address before the section of Obstetric 
Medicine and Gynaecology, says : " Looking back on forty years of 
gynaecological practice, I can recollect what has been termed a craze 
for inflammation and ulceration of the os and cervix uteri. During its 
prevalence, it was said of some devotees that every woman of a house- 
hold was apt to be regarded as suffering from these affections, and 
locally treated accordingly. Shortly afterw^ards came a brief and not 
very creditable period when clitoridectomy was strongly advocated as a 
remedy for numerous ills. This, fortunately, had a very limited currency 
and was speedily abandoned. Then followed a time in which displace- 
ment of the uterus held the field, and every backache, every pelvic dis- 
comfort, every general neurosis, was attributed to mechanical causes, and 
must needs be treated by uterine pessaries. Again we had an epoch 
when oophorectomy was not only recommended, and largely practised 
as a means of restraining haemorrhage in bleeding fibroids, but also as a 
remedy for certain forms of neurosis, even when the ovaries were healthy 
or not seriously diseased. Ere long it was discovered that removing the 
ovaries for neuroses, even if safely accomplished as far as life was 
concerned, was frequently followed by more serious nervous penalties 
than those for which it had been used as a remedy; that, in fact, 
it often entailed a loss of mental equilibrium, and sometimes ended 
in insanity. Close upon this, again, came an ardour for stitching up 
rents in the cervix uteri following child-birth, rents which were described 
as producing many hitherto unknown evils, and frequently conducing to 
the establishment of malignant disease. Lastly, we have had what has 
been described as an epidemic of operations for the excision of the uterine 

1 B 



SYSTEM OF GYNAECOLOGY 



appendages ; and even now, though this operation has but recently come 
into vogue, there is a reaction against its too frequent performance, and 
a demand in its place for more conservative methods, which shall leave 
these parts of the generative system a chance of still performing their 
important functions." 

Whatever may have been the mistakes or the delays in true progress, 
it is, at any rate, pleasant to know that the age of mere speculation and 
ignorant mysticism has passed ; and that the accurate knowledge and 
fuller certainties of the present day have been won by anatomical 
and pathological research, and by patient clinical observation both in the 
sick-room and the operating theatre. 

It will always be a pleasant task to acknowledge the deep debt of 
gratitude which gynaecology owes to Sir Joseph Lister ; for without his 
scientific discoveries and brilliant teaching the successes of modern 
pelvic and abdominal surgery could never have been won. 

The groundwork of all true development in any branch of medical 
science must lie in the establishment of an accurate knowledge of 
anatomical detail, and a correct appreciation of pathological changes. 
It may be well to review the advance of our knowledge in these sub- 
jects; and first in anatomy. 

Anatomy. — The hlood-supply of the uterus, by the uterine and ovarian 
arteries, has been well known and described by anatomists for many 
years past ; but the manner in which the blood is distributed to the organ 
had been less minutely studied: until Sir John Williams wrote his 
now classical paper " On the Circulation in the Uterus, with some of its 
Anatomical and Pathological Bearings," our knowledge of this important 
subject was extremely imperfect. Sir John Williams pointed out that 
the provision for the flow of blood into and out of the uterus is such, 
that the process could with difficulty be disturbed by mechanical causes. 
The entrance and the exit take place at the sides of the organ at 
numerous points, and not at its extremities ; while in the uterus the 
direction of the current is transverse to its length and perpendicular to 
its surface : a ligature might therefore be placed round the uterus at 
any point without affecting the circulation above and below. The only 
ligature which could materially interfere with the flow of blood into the 
uterus, or out of it, is one surrounding the broad ligaments (their upper 
borders being included within it), together with a portion of the uterus. 
In this case the inflows to the parts above or within the ligature, and the 
outflows from them, would be diminished or stopped. Conditions similar 
to this are found when the uterus forms a hernia, either in the inguinal 
canal or in the canal or pouch of Douglas. When the fundus of the 
uterus is found in the pouch of Douglas the condition is spoken of as a 
retroflexion or retroversion ; but it is really a great deal more than this : 
it would be as correct to speak of the condition found when the uterus 
is in the inguinal canal as anteflexion or anteversion. Both are true 
hernise, and the symptoms are due in great part to the constriction at 
the neck of the sac — in posterior hernia by the sacro-uterine ligaments. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 3 

There is another condition which may interfere with the return of 
blood from the uterus, namely, procidentia. Here all the veins of the 
broad ligaments may be so stretched that their channels may be 
considerably diminished, and all the channels for the return of blood 
from the uterus may be so narrowed that the organ must consequently 
suffer from passive congestion. These two conditions, herniee of the 
uterus and great procidentia, appear to be the only displacements of the 
uterus which can give rise to congestion of the organ. 

To those who remember the period in the development of gynsecology 
when uterine displacements were made to explain endless ills, it will be 
clear that the publication of the above essay made an enormous differ- 
ence in the value attributed to so-called mechanical causes. Nowadays 
a more rational view is taken of the importance of alterations or devia- 
tions from the ordinary position of the womb ; and it is recognised that 
very considerable changes in the position of the uterus are perfectly 
compatible with the enjoyment of excellent health. The outcome on 
the clinical aspect is easy to imagine ; pessaries are no longer recklessly 
inserted for every slight misplacement, but are retained for those more 
severe cases in which relief to an embarrassed circulation is clearly 
called for. 

Tlie Pelvic Peritoneum. — Good work has been done in the past years 
by those who have increased our knowledge of the anatomical and oljstet- 
ric aspects of the pelvic peritoneum. Thus Polk and Barbour have 
shown that in the full-term pregnant uterus the peritoneum in front and 
behind has the same relations as in the non-gravid uterus ; whereas, at 
the sides, the peritoneum is so lifted up by the growing uterus that the 
base of the broad ligament is on the level with the pelvic brim. Stephen- 
son concludes that the ligamental portions of the pelvic peritoneum 
offer considerable and permanent resistance to stretching beyond the 
limits of their elasticity ; and that the tension thus thrown on them is 
sufficient to undo their attachment to the pelvic walls. The peritoneum 
covering the uterus, however, instead of borrowing from neighbouring 
parts, undergoes a gradual yielding to an unlimited extent — growth 
supplying the additional material necessary to prevent thinning. The 
contrast is great between the unlimited expansion of the uterine peri- 
toneum, under the gradual increase in bulk of the ovum and its intol- 
erance of a rapid dilating force — a contrast aptly illustrated in the 
history of the induction of premature labour by the rupture of the 
uterus on the injection of but a few ounces of water. The peculiar 
property of the uterine peritoneum of gradually yielding under a small 
but persistent force, while breaking under a sudden one, confers upon it 
something of a plastic character. Dr. Stephenson remarks : '• Such being 
the properties of the serous coat, it is evident that it must play a part 
in the dynamics of the uterus. It furnishes a part of the persistent 
pressure inside the organ. It is also capable of taking a share in the 
retraction of the uterus. Whatever be the state of the muscular fibres 
of the uterus when labour is over, they are surrounded and supported by 



SYSTEM OF GYNAECOLOGY 



an elastic capsule, with, which any force tending to produce dilatation 
has to reckon. This idea is strongly supported by the anatomical fact 
that, in the portion of the uterine walls where reaction is manifested, 
the peritoneum is firmly attached ; whereas the parts where no active 
retraction occurs have either no peritoneal covering, or that membrane 
is but loosely attached thereto." 

The knowledge of this behaviour of the pelvic peritoneum under the 
disturbing influence of pregnancy is of immense importance to the 
gynaecological surgeon; for it enables him to estimate the probable 
changes in the anatomical arrangement of the membrane, when fibroid 
tumours or broad ligament cysts have developed in the pelvis, and have 
materially affected the relations of its parts. Again, in the rupture of 
tubal gestations, or in the formation of pelvic hsematoma from other 
causes, the effect of the peritoneal resistance on the development of 
these swellings is made clear. 

Tlie Connective Tissue of the Pelvis. — We are greatly indebted to the 
good work done by Hart and Barbour for our accurate knowledge of the 
manner in which the connective tissue of the pelvis is distributed. This 
tissue, lying subperitoneally, surrounding the cervix uteri, and spreading 
out between the layers of the broad ligament, is of the highest patho- 
logical importance, as in it, and in the pelvic peritoneum, occur those 
inflammatory exudations so common in women. 

Of late years our knowledge of the disposition of this tissue has been 
rendered much more accurate ; and, accordingly, our discrimination 
of pelvic inflammatory attacks made much more precise. The most 
valuable information is obtained by studying sections of frozen pelves. 
This method gives the precise position of the tissue, its amount and dis- 
tribution. By injections of air, water, or plaster of Paris, we have learnt 
the varying attachments of the pelvic peritoneum to the subjacent tissue; 
and the lines of cleavage, as it were, of the pelvic connective tissue along 
which lines pus will burrow. The valuable experiments of Bandl, 
Konig, and Schlesinger have given us the following results : — 

1. Water injected between the layers of the broad ligament, high 
up in front of the ovary, passed first into the tissue lying at the 
highest part of the side-wall of the true pelvis. It then passed into 
the tissue of the iliac fossa, lifting up the peritoneum, and followed the 
course of the psoas, passing only slightly into the hollow of the iliac 
bone. Lastly, it separated the peritoneum from the anterior abdominal 
wall for some little distance above Poupart's ligament, and from the 
true pelvis below it. 

2. On injection beneath the broad ligament to the side and in front 
of the isthmus, the deep lateral tissue became filled first ; then the 
peritoneum became lifted up from the anterior part of the cervix uteri ; 
thence the separation passed first to the tissue near the bladder; 
ultimately the fluid passed along the round ligament to the inguinal 
ring. There it separated the peritoneum along the line of Poupart's 
ligament, and passed into the iliac fossa. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 



3. An injection at the posterior part of the base of the broad liga- 
ment filled the corresponding tissue round Douglas' pouch and then 
passed on as described in the first section. 

Much might be written to show what extensive w^ork has been done 
to perfect our knowledge of the sectional anatomy of the female pelvis, 
of the structural anatomy of the pelvic floor, and of the position of the 
uterus and its appendages ; but the work already quoted will illustrate 
how full a share anatomy has had in the development of gynaecological 
science. 

Turning from the anatomical to the pathological and clinical aspects, 
it is interesting to note that the enormous strides which the science 
has made, and which have raised it from a desultory collection of 
hypotheses to its present high position, have all been taken in the 
last half century. It is true that in the early part of the century 
Recamier was advocating the use of the speculum and sound, and by his 
writing and teachings was given an impulse to the study of uterine 
pathology ; but it was not until about the year 1840, when Simpson in 
England and Huguier in France took the field with so much warmth, 
vigour, and originality, that interest was awakened and the future of 
gynaecology assured. Recamier, Lisfranc, Kiwisch, Huguier, Simpson, 
and others had already paved the way for further discoveries, when 
l)r. H. J. Bennet, in 1845, published the first edition of his work on 
Injiammation of the Uterus, and roused the attention of the profession 
in every country to the pathology which he there set forth. The chief 
points he insisted upon were the following : — 

1. That inflammation is .the chief factor in uterine affections, and 
that, as results, there follow from it displacements, ulcerations, and 
affections of the appendages. 

2. That menstrual troubles and leucorrhcea are merely symptoms 
of this morbid state. 

3. That in the vast majority of cases inflammatory action will be 
found to confine itself to the cervical canal, and not to affect the body 
of the uterus. 

4. That the disease is properly attacked by strong caustics. 

It is difficult for the modern student to apprehend the conflict of 
opinions which arose over these assertions of Bennet ; it is sufficient to 
say that his views were strongly controverted by such able writers as 
Tyler Smith, Robert Lee, West, and others ; and that in the present 
day few gynaecologists would be prepared to accept such statements 
without considerable modifications. 

Thanks to the study of microbic pathology, much evidence, that in 
those days seemed misty and conflicting, is read by us now in a totally 
different sense. The knowledge of septic organisms, the influence of 
specific microbes, the conditions of tissue-resistances, have opened out 
for us new ideas and new interpretations ; and it is probably not too 
much to assert that had Dr. Bennet possessed our advantages much of 
his pathology would have been rewritten. 



SYSTEM OF GYNAECOLOGY 



Another landmark in the history of the development of modern 
gynaecology was the publication by Dr. Tilt, in 1850, of his book on 
the subject of Ovarian Inflammation; later the same writer put for- 
ward the following propositions : — 

1. That the recognised frequency of inflammatory lesions in the 
ovaries and in the tissues which surround them, is of much greater 
practical importance than is generally admitted. 

2. That of all inflammatory lesions of the ovary those involving 
destruction of the whole organ are rare ; while the most numerous, and 
therefore the most important, may be ascribed to a disease that may be 
called either chronic or subacute ovaritis. 

3. That, as a rule, pelvic diseases of women radiate from morbid 
ovulation. 

4. That morbid ovulation is a most frequent cause of ovaritis. 

5. That ovaritis frequently causes pelvic peritonitis. 

6. That blood is frequently poured out from the ovary and the 
oviducts into the peritoneum. 

7. That subacute ovaritis frequently initiates and prolongs metritis. 

8. That ovaritis generally leads to considerable and varied disturb- 
ance of menstruation. 

9. That some chronic ovarian tumours may be considered as aberra- 
tions from the normal structure of the Graafian cells. 

Much of the pathology involved in these propositions of Tilt was 
sound, and has stood the test of time and more extended research ; and 
though, as in propositions three and four, his teaching is not nowadays 
accepted, yet by it a considerable stimulus was given to the study of 
ovarian pathology, and in testing the truth of his assertions more and 
more light was gained. Morbid conditions of the tubes had been but 
little studied in Tilt's time, and the relation of tubal disease to ovarian 
inflammation was hardly appreciated ; had tubal pathology been better 
understood, probably less weight would have been attached to morbid 
Ovulation as a cause of pelvic disease. 

The year 1854 marked a fresh epoch in the evolution of gynsecology ; 
then it was that the great war of uterine displacements and pessary- 
manufacture began. Hodge in America, Velpeau in France, and Graily 
Hewitt in England, stood forth as champions of the immense impor- 
tance of malposition of the uterus in the causation of pelvic disease. 
How strongly the theory was urged may be judged by Velpeau's state- 
ment : " I declare, nevertheless, that the majority of the women treated 
for other affections of the uterus have only displacements, and I aflirm, 
that eighteen times out of twenty, patients suffering from disease of 
the womb, or of some other part of this region, — those, for instance, 
in whom they diagnose engorgements, — are affected by displacements." 

Graily Hewitt, again, showed in his writings and teachings the 
enormous importance he attached to displacements of the womb ; in his 
well-known work on Diseases of Women he formulates the following 
opinions : — 



THE DEVELOPMENT OF MODERN GYNECOLOGY 7 

" 1. That patients suffering from symptoms of uterine inflammation 
are almost universally found to be affected with flexion or alteration in 
the shape of the uterus ; an alteration of easily recognised character 
though varying in degree. 

"2. That the change in the form and shape of the uterus is fre- 
quently brought about in consequence of the uterus being previously in 
a state of unusual softness, or what may be often correctly designated 
as chronic inflammation. 

" 3. That the flexion once produced is not only liable to perpetuate 
itself, so to speak, but continues to act incessantly as the cause of the 
chronic inflammation present." 

For a long time the teaching and literature of this epoch caused a 
vastly undue importance to be laid on the presence of every flexion or 
deviation, however slight. Every gynaecologist or practitioner who 
claimed special gynaecological merit, felt himself called upon to invent a 
pessary or to modify some one else's instrument ; and if, to quote Dr. 
Clifford Allbutt, " the uterus could justly complain that it was always 
being impaled on a stem or perched on a twig," it certainly could not 
complain that there was Avant of variety in the stem or monotony in 
the contour of the twig. 

Thanks to a more complete study of the circulation of the uterus by 
Williams, and to the teaching and practice of Matthews Duncan, a more 
correct appreciation of the importance of uterine displacement has been 
arrived at ; and we can recognise that it is possible for the uterine axis, 
as for the nasal septum, to be somewhat deviated without the patient's 
health being materially affected thereby. The value of a pessary in 
suitable cases is fully allowed ; but the instrument is no longer thought 
to be a panacea for every pelvic ill, or even a justifiable placebo to 
soothe the patient when diagnosis is at fault. 

Surgery. — Tlie next great era in the progress of gynce oology dates from 
the establishment of ovariotomy as a recognised operation ; for abdominal 
surgery, and especially that branch of it which had reference to disease 
of the uterus and its apx3endages, received its greatest impulse when it 
was found that ovarian cysts of the most formidable nature could be 
dealt with successfully and safely. Much discussion has arisen from 
time to time as to whom the credit of the first successful ovariotomy 
belongs, but it is now fairly certain that this honour rightly belongs to 
Dr. M'Dowell of Kentucky. 

The record of this first operation is of interest ; it was performed on 
a Mrs. Crawford of Kentucky, in December 1809. The tumour inclined 
more to one side than the other, and was so large as to induce her 
professional attendant to believe that she was in the last stage of preg- 
nancy. She was affected with pains similar to those of labour pains, 
from which she could find no relief. The incision was made on the left 
side of the median line, some distance from the outer edge of the rectus 
muscle, and was nine inches in length. As soon as the incision was 
completed the intestines rushed out upon the table ; and so completely 



SYSTEM OF GYNECOLOGY 



was the abdomen filled by the tumour, that they could not be replaced 
during the operation, which was finished in twenty-five minutes. In 
consequence of its great bulk Dr. M'Dowell was obliged to puncture it 
before it could be removed. He then threw a ligature round the Fallo- 
pian tube near the uterus, and cut through the attachments of the mor- 
bid growth. The sac weighed seven and a half pounds, and contained 
fifteen pounds of a turbid, gelatinous-looking substance. The edges of 
the wound being brought together by the interrupted suture and adhesive 
strips, the woman was placed in bed and put upon the antiphlogistic 
regimen. " In five days," says Dr. McDowell, " I visited her, and, much 
to my astonishment, found her engaged in making up her bed. I gave 
her particular caution for the future, and in twenty-five days she returned 
home in good health, which she continues to enjoy." Mrs. Crawford 
livQd until March 1841, and had no return of her disease. She enjoyed 
excellent health up to the time of her death. 

It must not, however, for a moment be supposed that the idea of 
ovariotomy originated with McDowell : years before, the Hunters had 
shadowed forth the possibility of removing ovarian cysts; and John 
Bell, of Edinburgh, though he had never performed ovariotomy, yet in 
his lectures dwelt with peculiar force and pathos upon the hopeless char- 
acter of ovarian tumours when left alone, and upon the practicability of 
removing them by operation. From this time forward operating sur- 
geons from time to time undertook the operation : sometimes a solitary 
case, followed by success or failure, sometimes a small group of cases 
(as published by Dr. Clay of Manchester in 1842) with a fair percent- 
age of success, were recorded ; but still the operation had not secured 
the confidence of the profession, and the records were few and far 
between. 

In 1850 Mr. Duffin inaugurated a new era by raising the question of 
the danger of leaving the tied end of the pedicle within the peritoneal 
cavity ; and by insisting upon the importance of keeping the strangu- 
lated stump outside. Of this step in the history of ovariotomy Spencer 
Wells writes : " Whatever may be our opinions and practice at the pres- 
ent time, and whatever views we may hold upon the question, whether 
this extraperitoneal treatment of the pedicle has advanced or retarded 
the success of the operation, Mr. Dufhn's arguments led to great changes 
and results — to the use of the clamp and to all the modifications of 
treatment attendant upon it, and ultimately to researches as to the 
physiological and pathological phenomena of ligatured stumps within 
the peritoneal cavity, and to the study of the important subject of 
drainage by Koeberle and others." 

Much might be said of the excellent work done by Baker Brown, and 
of his success with the cautery; also of Tyler Smith's revival of the 
practice of returning the pedicle with the ligature : but the history of the 
established and successful practice of ovariotomy dates from the publica- 
tion of Sir Spencer Wells's first book in 1864. From this time onward 
abdominal pelvic surgery has had a continuous story of forward progress. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 9 

step by step difficulties have been overcome, and each advance has been 
established on a sound scientific basis. 

Among the many useful points made clear by Spencer Wells that 
regarding the union of divided peritoneum was of special interest. Erom 
experiments made upon dogs, rabbits, guinea-pigs, and other animals, he 
was able to give visible evidence that, in the union of the cut surfaces of 
an abdominal incision, however accurately other tissues might be brought 
together, if the cut edges of the peritoneum are left free within the 
cavity they retract, direct union does not take place, and secondary evil 
consequences result. On the other hand, in specimens where the divided 
edges or rather surfaces of peritoneum have been pressed together, the 
smooth, serous, inner coat of the abdominal wall is perfectly restored. 
The stitches cannot be seen on the inside, though plainly visible on the 
skin ; and there is no adhesion of intestine or omentum. But in other 
specimens, where the peritoneal edges were purposely excluded from 
the sutures, and the animal was not killed for a day or two, intestine or 
omentum adheres to the inner surface of the abdominal wall, thus com- 
pleting the peritoneal sac at the great risk of intestinal obstruction ; to 
say nothing of a want of firm parietal union and subsequent ventral 
hernia. It was clearly demonstrated that, when skin or mucous mem- 
brane is divided, the edges must be brought together to secure direct 
union. If they are inverted, union is prevented. The exact opposite 
holds good with serous membranes. Their edges should be inverted 
and two surfaces of membrane pressed together, so that the sutures are 
not seen. The effused lymph then makes so smooth a surface that 
even the line of union cannot be seen. 

To those of us who have been brought up in the atmosphere of modern 
surgery, when the details of ovariotomy are carried out with almost 
universal agreement, it is difficult to realise the fierceness of the fights 
which raged round the comparative merits of a long or a short abdominal 
incision ; how bitterly the advocates of the intraperitoneal treatment of 
the pedicle regarded those who treated the pedicle by the extraperitoneal 
method and the use of the clamp, or how great was the importance 
attributed by each operator to his own special method of closing the 
wound ! Bit by bit evidence has been accumulated as to the desirability 
of using opium freely or sparingly after the operation ; as to the best 
mode of feeding the patient and maintaining her strength; as to the 
use of stimulants ; the modes of entry of septic poisoning, and the after 
consequences and complications of the operation. 

Ovariotomy in the course of its evolution taught us great things regard- 
ing the tolerance of the peritoneum even of rough handling and injury, 
provided nothing septic be left for absorption. Many details of treat- 
ment employed at present in abdominal surgery were learnt in the school 
of ovariotomy. In his address on "Abdominal Surgery Past and Present," 
delivered before the Medical Society in October 1890, Mr. Knowsley 
Thornton attempted to sum up the causes of slow progress and too frequent 
failure in abdominal surgery up to the year 1876, and to place the various 



lO SYSTEM OF GYNECOLOGY 



causes in what seemed to him to be their order of importance. He says : 
" We have lirst the general want of cleanliness and the lack of all apprecia- 
tion or knowledge of what constituted surgical cleanliness, then the long 
ligature and the clamp, both clumsy and unscientific, and both specially 
suited to make the want of cleanliness more deadly, and then following 
with an appreciable but far different influence, we have delay in operating, 
tapping, and the long incision. Then I must not forget drainage, for I 
think it is highly probable that a really good system of drainage, such 
as we now have, thanks to Koeberle and Keith, would have done much 
to counteract the evils I have named above, though the frequent use of 
the drainage tube, with the long ligature and the clamp, would have in- 
troduced new elements of risk, which I shall have to refer to again when 
I speak of the place which drainage occupies in the successes of to-day." 

Probably the long ligature and the clamp had less to do with failure 
than the want of knowledge of antiseptic precautions. At the present 
day we use a clamp round the pedicle of a fibroid tumour, we fix it in 
the lower angle of the abdominal wound, and yet we keep the wound 
and peritoneum perfectly free from septic mischief : moreover, in extir- 
pation of the cancerous uterus per vaginam we tie broad ligaments with 
silk ligatures, and leave long ends hanging down into the vagina till 
they come away ; and yet we do not get septic peritonitis. 

Probably delay in operating plays a more important part in results 
than we have hitherto supposed. The early ovariotomists had to under- 
take a large percentage of cases of long standing, cases in which the 
patient's strength had been exhausted by years of suffering, and in whom 
tissue resistance to the slighter or more severe forms of septic attack 
was greatly impaired; cases, moreover, in which dense and difficult 
adhesions to bowel, bladder, liver, and neighbouring parts had become 
organised in the long delay. At the present time the majority of these 
difficult cases have been cleared off, and in most of the cases now under- 
taken the health is still unimpaired, and adhesions (if present) are soft 
and easily separated ; moreover, long experience has taught us how to 
discriminate unsuitable cases of a malignant type, and these we have 
the wisdom to leave severely alone. 

No educated surgeon will ever minimise our vast obligations to Sir 
Joseph Lister; but, in fairness to the early operators, we may notice that 
Sir Spencer Wells had taken steps at a very early period to prevent the 
exposure of his cases to noxious influences. He did not allow surgeons 
who had been in contact with septic cases to be present at his operations ; 
he kept his wards for abdominal cases separate from wards in which 
patients with uterine sloughing cancer or other foetid diseases were 
present ; and he himself gave up all work in the post-mortem room. 
The dawning of better things in the way of surgical cleanliness had thus 
been shadowed forth before the full light of Lister's teaching had risen 
upon us. If in describing thus far the growth of ovariotomy the names 
of many eminent pioneers, such as Clay of Manchester, Atlee of America, 
Keith, and numerous other workers have received scanty recognition, it 
is because in the present article no attempt is being made to describe 



THE DEVELOPMENT OF MODERN GYNECOLOGY ii 

fully the evolution of ovariotomy, but only to show the place it took 
in the development of gynaecological science, and to emphasise some 
of the principal teaching and the elaboration of details which secured 
for it the present successful position. 

When once the removal of the ovaries in cases of cystic disease of 
these organs had become an established operation, it was to be expected 
that surgeons would consider the advisability of removing the uterine 
appendages for other morbid conditions : but no special move was made 
in this direction till about the year 1872, when we find that Hegar, 
Battey, and Lawson Tait all began to work in this special field. Bat- 
tey's original idea was to remove ovaries, not in themselves diseased, 
for the cure of certain nervous diseases, which he believed to be 
caused or kept up by structural or functional derangements of the 
ovaries. Hegar must have the credit of introducing the removal of 
ovaries for the cure of fibromyoma of the uterus ; while to Mr. Law- 
son Tait belongs the credit of introducing the operations for removal 
of diseased ovaries and tubes. 

It is now fairly well established that extirpation of the ovaries for 
various neuroses is practically a failure : the operation has been recom- 
mended in cases of insanity occurring at times of ovulation, in cases 
of hystero-epilepsy, also in hystero-neuroses other than epilepsy of se- 
vere character, but in very few instances has a cure been reported ; in 
the majority no good has been gained, and in a certain proportion the 
patient has been left mentally and physically in a worse condition 
than before. 

When, on the other hand, we study the cases in which the ovaries 
have been removed for the cure of uterine fibromyoma we find that a 
great step has been gained, and that Professor Hegar has added a val- 
uable resource to our treatment of these tumours. Knowsley Thornton 
considers that we owe an immense debt to Hegar for the introduction 
of this method of dealing with fibromyomas ; that the operation has, of 
course, its risks and its failures, but that, with care in the selection of 
proper cases, and Avith care in the removal of every particle of ovarian 
tissue, it is most satisfactory in its results, and is one of the most 
thoroughly scientific and valuable operations in the field of abdominal 
surgery. When we come to consider the removal of diseased ovaries 
and tubes, as recommended by Tait; and try to gauge the degree in 
which this operation can be called an advance in gynaecology, we have 
a difficult question to deal with — a difficulty mainly owing to the in- 
temperate zeal of many advocates of the operation. In cases in which 
tubes are filled with putrid or specifically diseased pus, and are dis- 
placed and badly adherent; or, again, when an ovary has become a 
mere bag of pus, displaced, and fixed by adhesions low in the pelvis, 
operation is urgently called for and should be undertaken. 

There are cases, also, in which the ovaries, for a long time the subject 
of chronic inflammation, may be displaced and adherent low in the pel- 
vis ; cases in which the tubes may be slightly thickened by mucoid de- 
generation, or are in an early condition of hydrosalpinx : in such cases 



12 SYSTEM OF GYNECOLOGY 

when the patient is drifting into chronic invalidism, is incapacitated 
from work, and is unequal to the duties of life, extirpation is certainly 
called for. On the other hand, to remove ovaries and tubes for early 
stages of sub-acute ovaritis, for slight degrees of pelvic peritonitis af- 
fecting the end of the tube and the ovary, for minor degrees of salpin- 
gitis, for ovarian prolapse apart from coarse disease, is to bring the 
operation into well-earned disrepute, and to retard rather than to ad- 
vance the progress of the science. It is, unfortunately, in the very 
cases in which the operation is most necessary that the greatest dan- 
ger arises ; for it is impossible to extirpate tubes full of foul pus or 
suppurating ovaries without great danger of fouling the peritoneum : 
moreover, in these cases the intestines are often so adherent, or so soft- 
ened by inflammation, that a great risk of rupture or of subsequent 
faecal fistula must necessarily be run. It has been well said that if the 
mortality could be obtained for all the cases of pyosalpinx operated upon 
in the United Kingdom since Tait introduced the operation, it would 
run the natural mortality of the disease very close indeed. There are, 
moreover, sundry objections to the operation which should be recognised, 
though they are frequently ignored. The operation does not by any 
means always lead to a permanent cure : a large proportion of patients 
operated upon suffer from continuance of the pains which preceded the 
operation; sometimes inflammatory products are formed which press 
on nerves and thus cause fresh troubles, or fix the uterus and thereby 
cause intense pain ; or grave mental symptoms may ensue ; or the ped- 
icle may suppurate and the healing of the wound be gravely delayed. 

Mr. Alban Doran summed up the position of the operation very 
satisfactorily when he remarked that it was very evident that removal 
of the appendages was an operation to be avoided whenever possible : 
and Professor Sinclair has wisely pointed out that operators are dis- 
posed to regard the woman's escaping with her life as constituting per 
se a satisfactory result ; whereas more attention should be paid to the 
ultimate effects upon the general health. 

In connection with this operation, we may properly consider the 
work done of late years both in Germany and in England, by which 
it has been shown that in many instances the mere breaking down of 
adhesions, without removal of either tube or ovary, is quite sufficient 
to relieve the patient of all her previous symptoms, and to restore her 
to an active, useful life. 

The revival of ovariotomy between 1858 and 1865 led, in the words 
of Paget, to an extension of the whole domain of peritoneal surgery. 
This extension, naturally enough, began with the removal of the uterine 
tumours. The removal of fibromyomas of the uterus has always been a 
much more serious matter than the performance of ovariotomy : thus up 
to the end of the year 1883, or thereabouts, such eminent operators as 
Schroeder, Martin, Tait, and Bantock had a mortality of 30 per cent, 
or even higher ; and though by improved methods and Avider experience 
Keith has shown that it is possible to have a mortality not much greater 



THE DEVELOPMENT OE MODERN GYNAECOLOGY 13 

than that of ovariotomy, still the operation in the hands of the majority 
of surgeons has not given such satisfactory results. The greatest gain so 
far has been brought about by Hegar's suggestion of the removal of tubes 
and ovaries as a method of procuring arrest of growth and subsequent 
atrophy of these growths. 

The rising generation of medical students is much more efficiently 
trained in obstetrics and gynaecology than was the case twenty years 
ago; and, doubtless, as fibroids of the uterus are recognised earlier, 
and cases of rapid growth of them are better watched and understood, 
Hegar's method will be applied in suitable cases with less delay, and 
at a time when removal of the uterine appendages is more feasible. 
We may thus hope less frequently to see large fibroid masses filling 
the abdomen and calling for abdominal hysterectomy with its greater 
mortality. 

It is not within the scope of this article to enter upon the various 
methods of operating for uterine fibroids, nor upon the various modifica- 
tions of existing operations ; but it is noteworthy that the most eminent 
gynaecological surgeons of the present day are not the most ardent advo- 
cates of frequent operating, and show their skill rather by their judicious 
selection of cases suitable for interference. Again, there is a decided 
tendency to prefer removal by abdominal section to any form of 
vaginal operation ; save in cases where submucous fibroids have already 
been partially delivered. As to the treatment of the pedicle of the 
tumour, when the growth is removed by abdominal incision operators 
are still divided in their choice between the extraperitoneal method and 
the intraperitoneal as advocated by Schroeder. Probably it will be 
found that each method has its advantages, and that the choice of 
method must be decided rather by the nature of the growth than by the 
fancy of the operator. While on the subject of fibromyoma of the 
uterus, it is impossible not to refer to the electrical treatment of fibroids 
which has been brought forward by Dr. Apostoli during the last few 
years. Many years ago it was asked whether fibroid tumours could be 
dispersed by the use of the galvanic current, but no satisfactory reply 
could be obtained. Apostoli has come forward claiming that he has 
found a means of applying currents so strong that destruction and 
shrinkage of the tumour is obtained without any damage to the patient's 
healthy tissues. According to his method, the operator applies a large 
clay pad over the abdomen in which is embedded the positive pole of a 
galvanic battery ; then a sound, made of platinum with the lower part 
protected by some insulating covering, is passed through the cervix into 
the uterus ; or, where this is impossible, a sharp-pointed steel sound, with 
all but the terminal half inch insulated by a protective coating, is plunged 
through the vaginal wall into the substance of the tumour : the connec- 
tions are now made, and a current, varying from 50 to 100 milliamperes 
or more, is allowed to pass. With reasonable care currents of this 
strength can be used without any damage to the wall of the abdomen. 
Many cases were brought forward by Apostoli to show us that under 



H SYSTEM OF GYNECOLOGY 

this treatment fibroids commonly shrink down to half or a third of 
their original bulk, and in many instances are practically destroyed with- 
out any sloughing or suppuration. The method has been fairly tested by 
numerous operators since its introduction, and it is to their results that 
we must look in deciding whether this electrical treatment of fibroids is 
to be regarded as an advance in our knowledge and modes of treatment 
or not. So far as can be decided at present, the result of the most recent 
inquiries has led us to the following conclusions : — 

1. The majority of fibromyomas (especially those of slow growth) are 
not reduced by the treatment. 

2. Soft fibromyomas are somewhat reduced in size by the use of the 
current. 

3. Haemorrhage due to submucous fibroids, or perhaps to the fun- 
gous endometritis so often associated with them, is greatly lessened. 
In these cases the positive pole is introduced into the uterine cavity, 
and the negative is connected with the abdominal pad. 

4. Considerable damage may be done to tissues in using this treatment. 
The opponents of Apostoli's method have pointed out that fibroid 

tumours of the uterus (especially the soft cellular form) may be reduced 
quite as satisfactorily by the use of rest, hot douches, and ergot, as by 
the use of electricity ; and with much greater safety. Also that the 
shrinkage obtained by the use of the current is by no means permanent. 
Again, as regards haemorrhage, the happiest results often follow the use 
of dilatation and curettage, so that there is no special advantage in 
employing the electrical treatment. Keith and other observers have 
spoken in terms of warm commendation of Apostoli's work, but so far 
they have not brought forward results which carry general conviction. 
More extended observation is needed, but at present it can hardly be 
said that the electrical treatment of fibromyoma of the uterus ranks 
high among our gains {yide art. " The Electrical Treatment of Diseases 
of Women"]. 

Extra-Uterine Pregnancy. — One of the results of the recent advances 
in abdominal surgery has been to give us a wider acquaintance wdth the 
pathology and treatment of those interesting cases in which the foetus is 
developed outside the uterine cavity. Much of our present knowledge is 
due to the investigation of Mr. Lawson Tait. Since Tait's first operation 
in 1883 for ruptured ectopic gestation — an operation which he performed 
successfully — great attention has been directed to the subject, and much 
advance in our knowledge has been made. Before this epoch extra-uterine 
gestation was thought to be one of the rarest events in the pathology of 
pregnancy : now we know that the accident is one of common occurrence. 
The older text-books taught much that was purely hypothetical on the 
subject ; thus they recognised a variety in which conception was affirmed 
to occur in the Graafian follicle, and development to take place entirely in 
the ovary. Tait pointed out that no museum specimen or post-mortem 
record gives any ground for such a view. 

Again, regarding the so-called abdominal form of ectopic gestation, it 



THE DEVELOPMENT OF MODERN GYNECOLOGY 15 

was believed that an ovum miglit be fertilised, drop into the peritoneal 
cavity on its way to the tubal opening, and grow from its beginning 
free in the peritoneal cavity. Without saying that this is impossible, 
we may assert that in our present state of knowledge the notion is 
purely imaginary, and is not borne out by any evidence of dissections. 
More extensive research and observation has led us to view almost 
every case as primarily tubal, commencing either — (i.) In the fim- 
briated end of the tube ; or (ii.) in the centre of the tube ; or (iii.) in 
the interstitial part of the tube. 

Much light has been thrown on the etiology of blood tumour in the 
pelvis by abdominal sections undertaken for ruptured tubal gestation ; 
and now it is clear that the majority of pelvic haematoceles and hsema- 
tomas are due to blood poured out from the end of the tube after rupture 
of the gravid tube or separation of the sac wall : in a few cases only 
can it be traced to such other causes as reflex of menstrual blood, 
hsemorrhagic peritonitis, rupture of veins in the broad ligament, and the 
like. No great advance has been made in our knowledge of the causes 
which lead to the production of an extra-uterine gestation ; but the 
hypothesis which has gained the widest hearing is that it is due to 
some lesion in the interior of the tube which obstructs the ovum in its 
passage to the uterus. This lesion is in some cases a desquamation of 
the epithelium of the tube, whereby the cilia are removed, and a pouch- 
ing of the tube may be produced in which the ovum remains instead of 
continuing its journey to the womb. In other cases a stenosis of the 
lumen of the tube is brought about by peritonitic adhesions which, in 
the course of their contraction, produce an angular bend in the tube, and 
so arrest of the ovum. The theory of lesion in the interior of the tube 
seems to cover a large number of cases ; and it is strengthened by the 
fact that a history of previous trouble on the same side of the pelvis 
can frequently be elicited. The event is often, though not always, pre- 
ceded by a period of sterility. The theory is also supported by the 
further supposition that the normal site of impregnation is in the uterus, 
and that if the ovum be delaj-ed, and impregnated in the tube, ectopic 
gestation results. Cases of ruptured tubal gestation, wdien examined 
on the post-mortem room table or during an abdominal operation, have 
taught us to what an extreme degree the ruptured peritoneum may be 
lifted from the pelvic walls and viscera by the gradual development of 
the foetus, or by repeated haemorrhages beneath the membrane. This 
elevation may reach as high as the umbilicus or even further. 

In a paper read before the Royal Medical and Chirurgical Society 
of London, Mr. Bland Sutton drew attention to the fact that the ovum 
in a case of tubal pregnancy, like the ovum in uterine pregnancy, is 
liable to become converted into a mole (apoplectic ovum). In Novem 
ber 1892 the same author brought a communication on " Tubal Moles 
and Tubal Abortion " before the Medical Society of London, and by his 
admirable drawings and accurate research added greatly to our know- 
ledge of this important condition. 



i6 SYSTEM OF GYNECOLOGY 

On the subject of tubal moles Bland Sutton says: "The retention 
of an impregnated ovum in the Fallopian tube leads to occlusion of the 
abdominal ostium, an event usually complete by the sixth, but often 
delayed to the eighth week following impregnation. It is therefore 
comparatively a slow process. When the ovum is lodged in the ampulla 
of the tube the ostium cannot close. So long as the tubal ostium re- 
mains open the ovum is in constant jeopardy of being extruded through 
it into the peritoneal cavity, especially when the ovum lies near or in 
the ampulla of the tube. When an impregnated ovum is thus extruded 
from the tube into the general peritoneal cavity, it is invariably in the 
condition of a mole, and the accident is always accompanied by haem- 
orrhage. The extrusion of a mole in this way is always indicated by 
the term ' tubal abortion.' Free haemorrhage may occur from a gravid 
tube and the mole be still retained in consequence of its attachment to 
the wall of the tube. Under such conditions the bleeding may be 
repeated. This is known as ' incomplete tubal abortion.' " 

Since the discovery of the tubal mole, specimens of occluded Fal- 
lopian tubes filled with blood, independent of tubal pregnancy, are now 
found to be infrequent. In the last report of the Museum of the Royal 
College of Surgeons (1892), a description is given of " An unequivocal 
example of Hsematosalpinx." This is a fair indication of the revolution 
which has taken place in our knowledge of the early stages of tubal 
pregnancy. There is one point in the treatment of ectopic gestation, 
advanced to term and in which the foetus is still living, which requires 
further study, and this is the treatment of the placenta after incision of 
the sac and extraction of the child. To strip off the after-birth from 
the underlying tissues would usually involve a terrible haemorrhage and 
probably the death of the patient ; yet to leave the placenta means, in 
too many instances, secondary septic changes and the death of the 
mother. Lawson Tait has recommended that the cord should be cut 
off close to the placenta, the sac washed out, and then sealed by stitch- 
ing it over the placenta ; the abdomen is then to be closed, and the 
after-birth left to be absorbed. 

The establishment of ovariotomy, leading as it did to the great exten- 
sion of peritoneal surgery, has led us to another great advance, namely, 
to the recognition of the benefits of abdominal drainage. Operators differ 
greatly in their estimate of the value of the drainage tube in abdominal 
surgery, but few in the present day will be found to deny its value in 
suitable cases. Whether in the treatment of pelvic abscess, in the 
case of suppurative or tubercular peritonitis, or again after the removal 
of foetid, closely adherent pelvic cysts, the drainage tube becomes of 
primary importance. For some time the question was debated whether 
an incision made into the vaginal roof to allow of a canula being 
drawn through from the peritoneal cavity into the vaginal canal were not 
the better method of drainage ; but it has been fairly well proven by 
Keith, Alban Doran, and other authorities, that the cavity of the peri- 
toneum can be more effectually emptied and kept free of exuded fluid by 



THE DEVELOPMENT OF MODERN GYNECOLOGY 17 

the glass drainage tube passed down from tlie abdominal wound into tbe 
floor of Douglas' pouch. Of course in some cases the use of the rubber 
tube or of iodoform gauze may possess a special advantage. ]S"o one who 
has witnessed the good effects of abdominal drainage \7ill doubt that in 
the recognition of this surgical expedient we have made a distinct 
addition to our surgical knowledge. 

No account of the Avork done in the develoi^ment of gyucecological 
science would be complete without a reference to the splendid achieve- 
ments of Marion Sims in the field of vesico-vaginal fistula. In numbers 
of women life was rendered one long period of suffering and distress 
until Sims brought his skill to bear on the subject of these lacerations. 
It is not difficult to picture the constant mental agony of a young woman, 
still in the prime of life, in whom the discomfort due to incontinence of 
urine and the foetor depending on clothes soaked with decomposing urine 
were horrors from which she could never escape. From the days of 
Ambrose Pare attempts had been made by Lallemand, Eoux, Gosset, 
Jobert de Lamballe, and many other surgeons, to find a satisfactory mode 
of closing these fistulas; but with what amount of success may be judged 
by the words of Yelpeau, who, writing in 1839, says: "To abrade the 
borders of an opening, when we do not know where to grasp them ; to 
shut it up by means of needles or thread, when we have no point 
apparently to secure them; to act upon a movable partition placed 
between two cavities, hidden from our sight, and upon which we can 
scarcely find any purchase, seems to be calculated to have no other 
result than to cause unnecessary suffering to the patient." 

In 1852 Sims brought out his perfected method of healing these 
rents in the floor of the bladder ; and gained a series of successes which 
entirely altered the aspect of this special domain of surger}^ He laid 
claim to three discoveries ; nameh', that he had produced a speculum 
which enabled an operator to explore the vagina perfectly ; that he had 
found a suture, which was not liable to set up inflammation or ulcera- 
tion ; and that by the use of his catheter, the bladder could be kept 
empty during the healing of the fistula. 

Sims was shortly afterwards followed by Simon of German}', and to 
the efforts of these two workers we owe our present satisfactory know- 
ledge of the subject. Simon himself laid great stress on the importance 
of the operation called by him kolpokleisis, or closure of the vagina — an 
operation to be resorted to in cases in which the cure of a vesico-vaginal 
fistula could not be successfully accomplished. Doubtless such a surgical 
resource may be found valuable occasionally; but the cases must be rare 
in which the fistula cannot be closed by patience and perseverance. Year 
by year, however, fewer cases of these fistulous openings occur. Better 
hygienic surroundings have told favourably on the young girls of the 
present day, and pelvic contractions are less frequent ; the frequent use 
of the midwifery forceps and their earlier application, prevent the foetal 
head from resting so long on the mother's soft parts, and prevent the 
sloughing of her anterior pelvic tissues ; and an increased knowledge of 

c 



SYSTEM OF GYNAECOLOGY 



the mechanism of delivery has led to a more successful management of 
difficult labours. 

Reference may be made here to certain plastic operations which have 
been devised in connection with the vagina; for instance, plastic opera- 
tions for lessening the calibre of the vagina, others for preventing prolapse 
of the uterus, plastic operations on the cervix, and so forth, but none of them 
has takenavery firm hold on the surgical world. In the same category might 
be placed sundry operations which have been devised of late years for fix- 
ing the uterus ; thus Alexander's operation of shortening the round liga- 
ments in cases of uterine prolapse, hysteropexy or fixation of the womb to 
the posterior surf ace of the parietal peritoneum, detachment of the vagina 
from the anterior wall of the uterus with opening of the anterior peri- 
toneal cul-de-sac, and forward fixation of the uterus — these and sundry 
other operations have all their earnest advocates, but I have not given 
them a recognised place in uterine surgery ; for it cannot be said as yet 
that they have secured the confidence of the gynaecological world ; they 
are rather on their trial than accepted as proven remedies. 

Malignant Diseases. — The ancient writers were doubtless acquainted 
with cancer of the uterus, but their knowledge was narrowly limited ; 
and we may certainly claim that in the last fifty years we have made 
great advances in our knowledge of the pathology and clinical course 
of malignant diseases of the female genital organs. It is a matter of 
extreme regret that we have hitherto made so little progress in our 
modes of treatment, and are still so far from an acquaintance with any 
curative method. 

Even in the earlier part of the present century the knowledge of 
uterine cancer was very shadowy ; for Church, writing in 1864, says : 
" If we compare the writings of different persons, and those men of great 
experience, we shall find many points of interest undetermined, and 
others the subject of incessant controversy. Very frequently the descrip- 
tion of the disease conveys only a lively picture of the uncertainty of the 
writer ; and so vague, indeed, is the sense in which the term cancer is 
sometimes applied, especially by the French authors, that it would be 
quite impossible to recognise the complaint from their description.'^ Den- 
man fully appreciated the uncertainty of the description generally given. 
He says : " Of cancer it is to be lamented that we have at present neither 
a tolerable definition nor a correct history, nor any accurate distinction 
of the several varieties which are certainly known to exist. Nor is 
it yet proved whether cancer of any part has any specific quality ac- 
cording to the structure of the part affected ; nor have we, in fact, any 
other idea than that it is an incurable disease. Till within quite recent 
years cancer was often confounded with fibroid tumour of the uterus, and 
the division into schirrus, encephaloid, epithelioma, and colloid was com- 
monly quoted in the text-books of the day. Moreover, the term 'cor- 
roding ulcer' was applied by Dr. John Clark, and subsequently Sir 
Charles Clark, to a form of ulcer of the cervix in which nothing but rapid 
destruction of tissue is noticed as a pathological lesion; in which there 



THE DEVELOPMENT OF MODERN GYNECOLOGY 19 

is no hardness of the part affected, no induration nor inflammation of sur- 
rounding organs — nothing but molecular death in the cervix uteri, and 
disappearance of its structure as by liquefaction. It has been described 
under the names of rodent ulcer, diffuse ulcerative cancer, epithelial 
cancer, and cancroid of the uterus." Many other authors might be 
quoted to show how little certainty existed. 

A decided step in advance was taken when Thiersch and Waldeyer 
laid down that all cancerous disease in the uterus takes its origin from 
the epithelium lining glands which dip down into the parenchyma. 
''Only Thiersch, and recently Waldeyer," says Billroth, "maintain as 
I do the strict boundary between epithelial and connective tissue cells. 
I only call those tumours true carcinomata which have a formation similar 
to that of true epithelial glands (not the lymphatic glands), and whose 
cells are mostly actual derivatives from true epithelium." At one time 
surgeons were doubtful whether malignant disease arose more often in 
one part of the uterus than in another ; but another advance was made 
when Sir Charles Clark wrote that "carcinoma particularly affects 
glandular parts, and the cervix of the uterus being the most glandular 
part of it, is probably the reason why it becomes more liable to this 
disease than any other part of the viscus." 

Before this time Dr. Burns had laid down in his work that " as 
opportunities are not frequent of examining the womb in the early stage 
of the disease, and as in course of time it involves parts not at first 
affected, we have not yet decided what the comparative liability of 
different parts of this viscus is to the disease." Virchow advanced our 
knowledge still further by his investigations into the differences between 
malignant cauliflower excrescences and non-malignant papilloma. He 
stated his belief that some tumours, in every respect resembling vege- 
tating epithelioma, are really non-malignant papilloma. The difference 
between the latter and real epithelioma is to be found by microscopic 
examination of the submucous tissue, which in the one case is healthy, 
in the other case diseased. In 1888 Williams published his well-known 
Harveian Lectures on uterine cancer^ and summed up fairly the extent 
of our present knowledge. 

Three varieties of malignant disease affect the uterus — sarcoma, car- 
cinoma, and adenoma. In the uterus sarcoma and carcinoma are always 
malignant; adenoma often, but perhaps not always. The uterus is divided 
into three parts, mainly according to the character of the epithelium and 
of the glands met with in §ach part. The first is the vaginal portion : this 
portio vaginalis is really a cup of stratified epithelium, resembling a 
tailor's thimble, which fits on the lower end of the cervix proper. The next 
part is the cervix, and the third is the part above which constitutes the 
body and fundus of the organ. These divisions are of importance because 
cancer may begin in any one of them, and the disease generally presents 
different characters, runs a different course, and is amenable to treatment 
in different degrees, according as it begins in one or other of them. 

In the first division the disease is almost always a squamous 



SYSTEM OF GYNECOLOGY 



epithelioma. In this case the lines of growth are not towards the cavity 
of the uterus, but outwards and downwards towards the vagina ; it 
creeps towards the vaginal vault, and then down along the surface of 
the vaginal walls. There is no evidence that laceration of the cervix 
plays any part in the etiology of this form of cancer ; but most of the 
cases occur in women who have borne children. 

In the second division we find disease occurring with much greater 
frequency. The starting-point of the cancer of the cervix seems to be 
always in the glands of the cervix ; and if we study the lines of growth 
of the disease, we find that it usually spreads downwards and outwards 
into the surrounding cellular tissue. The vaginal walls are usually 
spared. 

In the third division we have cases of cancer of the body of the 
uterus. This part of the uterus is much less commonly the seat of the 
disease than is the cervix ; at one time, indeed, it was doubted whether 
cancer ever originated primarily in the body, but numerous undoubted 
cases have been brought forward to prove the statement. All cancers 
of the body seem to be of the columnar epithelioma kind. They occur 
most often after the age of fifty ; they give rise at an early period to 
much pain and flooding ; they are more common in nulliparous patients, 
and, once begun, they involve the whole surface of the body, though 
they tend to respect the cervix. In the later stages the disease passes 
through the internal os and attacks the cervix ; it also spreads deeply, 
involves the muscular wall, and may pass through it. 

No description of the evolution of this subject would be complete 
without reference to the admirable work done by Euge and Yeit in 
investigating the true nature of granular erosions of the cervix, and in 
showing how these lesions differ from early manifestations of true cancer. 
An erosion differs from cancer in that the epithelium on its surface 
and lining its glands consists of a single layer and assumes no aberrant 
forms ; and from adenoma of the cervix, in that the glands are compara- 
tively superficial. A simple erosion, again, bleeds less readily when 
touched than does the early ulceration of commencing malignant growth. 

As regards the treatment of uterine cancer but little can be said. 
During the last ten or fifteen years a considerable controversy has 
been raised concerning the rival merits of supravaginal amputation and 
total extirpation in cases of cervical carcinoma. Most authors are 
agreed that removal of the cervix is sufficient when the portio vagi- 
nalis alone is affected ; but there is not the same agreement when the 
disease attacks the upper part of the cervix. Martin of Berlin and 
Fritsch of Breslau have published numerous cases of total extirpation 
of the uterus for cervical cancer ; but their reports, and those of other 
skilful operators, have only demonstrated that the operation can be done 
by experienced surgeons with a very low rate of mortality. Williams 
argues that in cases of cervical carcinoma supravaginal amputation does 
all that is needful, and that no advantage in the prevention of recurrence 
of the growth is gained by the larger operation. His views, however, 



THE DEVELOPMENT OF MODERN GYNECOLOGY 21 

have by no means met with general acceptance by the profession ; and 
the opinion seems to be gaining ground that if, in a case of cancer of the 
true cervix, an operation be recommended, total extirpation will prob- 
ably give the best result. Attempts at progress are being made at 
present principally in the direction of early diagnosis ; and surgeons are 
endeavouring, by microscopical examination of scrapings removed v/ith 
the curette, or of sections taken from the suspected cervix with knife 
or scissors, to gain early and certain knowledge while the disease is 
still narrowly limited and surrounding tissues not invaded. 

Sarcoma Uteri. — Very little was known about this affection by the 
early authors of this century. Keference is found in gynsecological 
literature from time to time to certain forms of fibroid tumours which 
had a tendency to return after removal ; and the term " recurrent fibroid " 
was often used. Sir James Paget put these tumours into three divisions, 
namely, (i.) malignant fibrous tumours, (ii.) recurrent fibroids, (iii.) mye- 
loid tumours. Lebert described them as fibro-plastic tumours and Eoki- 
tansky gave them the title of fasciculated cancer. Virchow was the first 
to give a clear and intelligent description of these growths, and to put 
them under the head of sarcoma. Gusserow and other observers in Ger- 
many, following on the steps of Virchow, have of late years given careful 
study to uterine sarcoma. Eesembling, as it does, cancer of the uterus 
in many respects, there are certain well-established points of clinical dis- 
tinction between them. At one time it was thought that the disease 
always arose in the body of the uterus, and never began primarily in 
the cervix ; but this has now been shown by Yeit and others to be a 
mistake, though of course the large majority of cases are of the former 
variety. Primary sarcoma of the uterus occurs anatomically and clini- 
cally in two distinct forms, namely, (i.) fibro-sarcoma, which forms a 
more or less firm, circumscribed, rounded tumour growing from the 
uterine parenchyma; and (ii.) diffuse sarcomatous tumours growing 
from the connective tissue of the uterine mucous membrane, and com- 
posed mostly of small round cells. 

Between diffuse sarcoma and carcinoma of the fundus the diagnosis 
has to be made almost entirely by the microscope. While we have still 
much to learn regarding malignant affections of the genital organs, we 
may congratulate ourselves that our knowledge has become more definite, 
better founded, and more concise. We may here notice that much know- 
ledge has been gained by a more frequent use of cervical dilatation; and 
in this respect much gratitude is due to Professor Hegar for his admir- 
able mechanical dilators. It is true that dilatation and curettage were 
practised in the days of Eecamier, but not to any considerable extent. So 
long as surgeons had to trust to slow dilatation of the cervix with tents, 
and had to consider the risks of septic inflammation consequent on the 
use of this mode of opening up the cervix, the operation was compara- 
tively seldom resorted to ; but the present method of rapid dilatation has 
removed much of the difficulty, and has enabled us to explore the cavity 
of the uterus quickly and safely. In cases of haemorrhage occurring at 



SYSTEM OF GYNECOLOGY 



or about the time of the climacteric, cases in which the uterus is found by 
bimanual examination to be distinctly enlarged, this method of explora- 
tion is of immense service ; for it enables us with the curette or the hnger 
to remove small portions of the hypertrophied mucous membrane, and 
to determine promptly by the microscope whether the tissue be malignant. 
Believing, as now we do, that some forms of malignant growth have what 
may be termed a precancerous stage, it becomes of immense importance 
to ascertain the character of the disease at an early period. 

No great advance has been made in our knowledge of malignant 
affections of the vagina and vulva; but the paper of Dr. Matthews 
Duncan on lupus of the vulva, published in the 27th vol. of the Trans- 
actions of the Obstetrical Society of London, has materially advanced our 
knowledge of this rare disease. In this communication Duncan 
pointed out that though vulvar lupus lacked many of the histological 
characters of lupus vulgaris, yet in its tendency to erode and destroy it 
closely imitated the latter disease. Lupus included ulceration, inflamma- 
tion, and hypertrophies, variously combined ; states which were not can- 
cerous, not epitheliomatous, and not syphilitic. It may turn out that 
several diseases are included in this comprehensive term ; but at present 
they are combined in one description on account of their apparent 
similarity. They are far from being so uncommon as is sometimes 
supposed. 

Pelvic Inflammation. — In endeavouring to trace the development of 
our knowledge regarding acute inflammations occurring in the pelvis, we 
may date our researches from the year 1840 or thereabouts. Before 
this time, though abscess of the womb had been mentioned by such 
early writers as Aetius and Paul of ^gina, yet no systematic study of 
the affection had been made. However, after the year 1840 many 
observers were at work. Thus in 1841 Bourdon had written on " Fluct- 
uating Tumour of the True Pelvis " ; Doherty in 1843 had given us his 
views on chronic inflammation of the uterine appendages ; Calvi in 1844 
had described " Intrapelvic Phlegmonous Abscess " ; while in the same 
year Churchill and Lever had contributed to our knowledge of the 
subject. A little later, in 1846, Nonat was doing good work in the 
same field. Any one, however, who reads the medical history of these 
times will see clearly that the gyneecologists of those days were under 
the impression that all the pelvic exudations or abscess sacs were solely 
due to inflammation, or maybe to suppuration, occurring in the cellular 
tissue of the true pelvis. Such terms as pelvic abscess, peri-uterine 
phlegmon, parametritis, and pelvic cellulitis, all meant practically the 
same thing, namely, connective tissue inflammation. The first advance 
in our knowledge came through Bernutz : in 1857 a case of so-called peri- 
uterine phlegmon came under his care and the patient died. At the 
post-mortem examination the pelvic tumour which had been supposed to 
be formed by inflammation of the pelvic cellular tissue was found to 
consist of bladder, nterus, broad ligaments, and sigmoid flexure all 
matted tos^ether. The cellular tissue of the broad ligament and uterus 



THE DEVELOPMENT OF MODERN GYNECOLOGY 23 

was not involved, and no real peri-uterine phlegmon existed. The study 
of this and similar cases caused Bernutz and Goupil about the year 1862 
to publish their classical memoir, in which abundant clinical and post- 
mortem evidence was brought forward to prove the true nature of the 
swellings previously ascribed solely to the effect of pelvic cellulitis. 
Bernutz summed up his views as follows: — 

1. That inflammation of the pelvic peritoneum is a disease very 
commonly met with. 2. That the tumour found after death in cases of 
pelvic peritonitis is formed by the matting together of various pelvic vis- 
cera as a consequence of this inflammation. 3. That inflammation of the 
pelvic serous membrane is always symptomatic, and that it is generally 
symptomatic of inflammation of the ovaries or of the Fallopian tubes. 

Old theories, however, die hard; and, though Bernutz had brought 
forward such abundant proof in support of his assertions, yet for many 
years his views met with little general acceptance by the majority of 
gynaecologists, and the old views continued to be taught and held. 
Even such a keen observer as the late Matthews Duncan thought that 
Bernutz had been over-zealous in estimating the comparative frequency 
of pelvic peritonitis and the rarity of pelvic cellulitis. For some years 
opinions were strongly divided upon the comparative frequency of cel- 
lulitis and peritonitis. With the narrowness and bitterness born of 
imperfect knowledge, some authors laid down strongly that in pelvic 
peritonitis cellulitis only exists as a complication ; while others were as 
ready to assert that cellulitis is in all instances the primary affection, 
and that the inflammation only spreads secondarily to the peritoneum. 
Writing in 1880 Dr. Gaillard Thomas, however, records his conclusions 
under four distinct propositions, namely : — 

" 1. Peri-uterine cellulitis is rare in the nonparous woman, while 
pelvic peritonitis is exceedingly common. 2. A very large proportion 
of the cases now regarded as instances of cellulitis are really cases of 
pelvic peritonitis. 3. The two affections are entirely distinct from each 
other, and should not be confounded simply because they often compli- 
cate each other ; they may be compared to serous and parenchymatous 
inflammation of the lungs — pleurisy and pneumonia. Like them they 
are separate and distinct, like them they affect different kinds of 
structure, and like them they generally complicate each other. 4. They 
may usually be differentiated from each other, and a neglect of the 
effort at such thorough diagnosis is as reprehensible as a similar want 
of care in determining between pericarditis and endocarditis." 

Again, in 1886, Hart and Barbour state that there is now little 
doubt that Bernutz and Goupil pushed their views too far; and that in 
America, Germany, and Britain gynaecologists now consider pelvic 
inflammation as both peritonitic and cellulitic. Moreover, they note 
that both diseases are always combined. Thus in a marked pelvic peri- 
tonitis there is always some pelvic cellulitis, and in a marked pelvic 
cellulitis there is always some pelvic peritonitis. This is quite analo- 
gous to what is found in pneumonia and pleurisy. Thus w^e may fairly 



24 SYSTEM OF GYNECOLOGY 

conclude from the result of modern investigations that inflammation 
both of the cellular tissue and also of the serous membrane may arise, 
but that of the two the latter is certainly the more frequent. 

Much good work has been done of late years in developing our 
knowledge of the causation of pelvic cellulitis and peritonitis. In the 
case of the former disease recent investigations go far to show that the 
introduction of septic particles into the lymph circulation, by way of 
rents after operation, abortions, or full-term deliveries, is most com- 
monly the cause of the mischief. Many good observers would go so 
far as to say that they know of no possibility of cellulitis unless some 
septic virus has been introduced into the vagina, and been absorbed 
through some abrasion or fissure in the mucous membrane of the vagina, 
cervix, or uterus. Certainly such indefinite causes as catching cold, 
exposure to chill, strains, and the like, are more and more regarded 
with suspicion ; and attention is concentrated on the possibility of the 
introduction of micro-organisms with its septic consequences. 

As regards the production of pelvic peritonitis, the point of most 
interest is to consider how frequently the disease is consequent on a 
pre-existing salpingitis. In 1893 Dr. Cullingworth published his re- 
searches into this question. Under the heading of '' Pelvic Inflamma- 
tion usually a Peritonitis originating in Salpingitis," he says : " The 
usual state of things disclosed on opening the abdomen in these cases 
is as follows : — 

" The contents of the pelvis are generally concealed from view by 
the great omentum, which has been drawn down so as to cover them 
anteriorly, and has contracted adhesions to the peritoneum as it becomes 
reflected on to the anterior abdominal wail, as well as to the uterus and 
other pelvic viscera. Along with this screen, as it were, of omentum, 
it is not unusual to find coils of adherent small intestine. On separat- 
ing and drawing aside the screen, one side, or it may be the whole of 
the posterior part of the true pelvis, is seen to be occupied by what 
seems to be an indistinguishable mass of matted viscera. The uterus 
itself is sometimes implicated in the mass, but in other cases its upper 
part at least is free. Tracing the Fallopian tube outwards from the 
uterine corner on the side of the disease, it is often found to be normal 
in size for the first half inch or so, and then to become involved in the 
adherent mass. This mass, on being separated and brought into view, is 
invariably found to consist of the uterine appendages more or less altered 
by inflammation. There is always salpingitis, and the inflamed and thick- 
ened tube commonly enfolds the ovary, which is frequently normal." 

With regard to the tubes the first point to be noted is that the 
evidences of peritoneal inflammation are always most marked in the 
neighbourhood of the fimbriated end ; this shows clearly that the pelvic 
peritonitis has originated by direct extension from the mouth of the 
inflamed tube, or by the escape of morbid secretions therefrom. Where 
the secretion from the inflamed tube is chiefly mucous in character, with 
only a slight intermixture of pus corpuscles, the intensity of the inflam- 



THE DE VEL OPMENT OF MODERN G YN^COL OGY 25 

mation round the abdominal ostium is shown by the extreme density of 
the adhesions at that spot and nothing more. Where the secretion, on 
the other hand, is wholly purulent, one of two things is found to have 
happened according to whether the fimbriated extremity remains patu- 
lous or has become closed. In the former case an intraperitoneal abscess 
is found, encysted among adhesions, and fed by the purulent discharge 
issuing from the open mouth of the suppurating tube ; in the latter 
case the pus by its accumulation distends the occluded tube and forms a 
pyosalpinx. Mr. Alban Doran, in his address before the East Anglian 
Branch of the British Medical Association in 1893, shows that tubercu- 
lous disease commencing in the ovaries and tubes may spread outward 
and involve the peritoneum, setting up tuberculous pelvic peritonitis. 
In one case under my own care this was very well shown. On opening 
the abdomen of a young woman the left ovary and tube were found 
matted together, and studded with small masses of tuberculous material : 
the peritoneum as a whole was healthy ; but in the immediate neigh- 
bourhood of the diseased tube and ovary it was infected, and showed 
similar foci of tuberculous disease, — in other words, a localised pelvic 
peritonitis had been set up. It is clear, then, that in a large number 
of cases the peritonitis is due to some mischief originating in the ovary 
or tube ; but neither clinical nor post-mortem evidence has yet brought 
us to believe that the disease is always secondary to some pre-existing 
morbid condition of the uterine appendages. 

A form of pelvic peritonitis has been described by ]\ratthews 
Duncan and others under the name of "encysted serous perimetritis." 
The peculiar feature is that one or several collections of serous or sero- 
purulent fluid are found pent up among coils of intestines. The collec- 
tion may occupy the pouch of Douglas, and press the floor of the 
pouch so forcibly downwards that the perineum is bulged. In many 
cases of pelvic peritonitis small collections of serous fluid are found 
pent up by adhesions between the coils of intestines ; but the disease is 
seldom specially described as serous perimetritis unless the amount of 
fluid pent up be very extensive. Before leaving this subject attention 
must be called to the extension of our knowledge regarding pelvic 
abscess ; from what has been already noted, it is clear that collections 
of pus in the pelvis are by no means always due, as had been supposed, 
to suppuration of the pelvic connective tissue. Operative surgery has 
done much to increase our pathological knowledge in this respect : and 
we now know that many so-called pelvic abscesses are really suppurating 
dermoid ovarian cysts adherent low in the pelvis, or perhaps tubes filled 
with pus; or they may be suppurating hgematoceles, or extra-uterine 
gestation sacs. This thought brings us to the subject of treatment in 
cases of pelvic inflammation. 

With a more exact knowledge of the morbid anatomy and clinical 
history of these cases of pelvic inflammation our treatment has under- 
gone considerable modifications ; and to a large extent active surgical 
interference has taken the place of a treatment purely medical and pallia- 



26 SYSTEM OF GYNAECOLOGY 

tive. Indeed, as has been already pointed out, there has been a marked 
tendency to resort to the use of the knife in an undue percentage of 
cases ; and often, too, in an early stage of the disease before time and 
observation have shown us what the natural powers of repair are capa- 
ble of doing. The case is different when the presence of pus can be 
demonstrated with a fair amount of certainty; for, as an eminent surgeon 
has well said, a collection of pus calls for the same treatment, whether it 
occur in the mammary gland or in the pelvis, and opening of the abscess 
with evacuation of the pus is urgently demanded in either case. 

Disorders of Menstruation. — The division of these disorders into 
three groups, namely, amenorrhuea, menorrhagia, and dysmenorrhoea, is 
a very old one and a very excellent one. In the last fifty years our 
knowledge of menstruation and its variations has undergone consider- 
able development, not only through the revelation of new facts, but yet 
more by the exclusion of much that was purely imaginary and false. 
Several points of considerable discussion and doubt may be considered 
as finally settled. Thus that menstrual blood does not coagulate is 
known now to depend on a certain admixture of mucoid secretion from 
the cervix and uterus. Provided that the menstrual blood be not in 
excess, and, secondly, that a certain proportion of healthy mucus 
be secreted, we may be sure that the blood will remain fluid : but if 
an excess of blood be poured out from the uterine wall, and the mucus 
be therefore relatively deficient in amount; or if the mucus secreted be 
morbid in quality or positively deficient in amount, we are certain to 
find that the menstrual blood does clot. The coagulation which occurs 
in cases of bleeding submucous fibroids, or again in certain forms of 
endometritis, illustrates this point. 

Another point which has received considerable attention concerns 
the histology and alterations of the uterine mucous membrane during 
menstruation. Study of the infantile uterus by Willia-ms and others 
has shown that to speak of the layer of tissue superficial to the mus- 
cular fibres as the mucous membrane is not correct ; for the human foetal 
uterus shows a distinct submucous layer just beneath the peritoneum, 
so that the whole of the tissue is internal to this mucous membrp^ne. 
Nearly the whole of the muscular thickness of the human uterus is 
therefore '^muscularis mucosse," and the apparent absence of a sub- 
mucous coat is thus accounted for. 

Another interesting question, which has been discussed lately, and on 
which much light has been thrown, is that of the rhythmical contractions 
of the uterus which occur during menstruation. Viewing menstruation 
as a miniature labour, one would expect that rhythmical contractions, 
akin to the recurring pains of parturition, would be set up at the men- 
strual epoch ; and some years ago Braxton Hicks and others stated their 
belief that these contractions occur. Clear evidence of the fact is af- 
forded by the behaviour of a uterus which contains a fibroid polypus ; 
for with the onset of the catamenia the internal os is dilated, the cervi- 
cal canal becomes patulous, and the external os is enlarged, so that the 



THE DEVELOPMENT OF MODERN GYNECOLOGY 27 

finger can be introduced and the tumour felt. As the menstrual period 
passes the canal closes down again, and the internal os becomes closed. 
Again, if the cervical canal be tested by the passage of graduated 
bougies before and during the first few days of menstruation, the same 
opening of the cervical canal by the force of the uterine .contractions 
can be observed. Sir John Williams has stated that the uterus contracts 
during menstruation, because the cavity after menstruation is smaller 
than it would be if the mucous membrane were gone wdthout uterine 
contractions. The importance of the recognition of this fact will be 
seen when we come to study the causation of pain in connection wdth 
menstruation. In speaking of the changes which occur in the mucous 
membrane of the uterus at and about the menstrual epoch, it cannot be 
said that our knowledge has made much advance; there are many 
opinions on the subject, but little definite knowledge. IModern research 
has made one point fairly certain, namely, that the whole of the mucous 
membrane of the uterus is not shed every month; but rather that 
certain changes of a hypertrophic and fatty degeneration occur which 
lead to the exfoliation of the superficial part of this membrane. The 
papers bearing on this subject by Kundrat and Engelmann, Leopold, 
Williams, Wyder, and others, are too well known to call for farther 
comment. 

Amenorrhoea. — No great advance has been made in our knowledge or 
treatment of amenorrhoea. In cases of imperforate hymen common sense 
has taught us that repeated aspirations are quite unnecessary, and that 
free incision of the hymen under antiseptic precautions, followed by rapid 
evacuation of the retained menstrual fluid, is a safe and scientific mode 
of treatment. If the opening made in the hymeneal membrane be free 
and patulous, there is little risk of fluid regurgitating down the Fallopian 
tubes, even though these latter be somewhat dilated. Under modern 
antiseptic precautions one never sees the rapidly fatal instances of septic 
peritonitis which used every now and again to terminate these cases. In 
the production of healthy menstruation, it is recognised that a healthy 
anatomical tract from the ovary to the hymen, a healthy condition of the 
blood, and a sound state of the nervous system are required ; so in con- 
sidering the causation of amenorrhoea (if we exclude pregnancy, lactation, 
delayed onset, and the menopause), it is clear that all cases must come 
under one of these headings. 

In his lecture on sterility, Matthews Duncan drew attention to 
an interesting condition of what he termed •' one-child sterility." In 
these cases a healthy but delicate young woman, usually of the upper 
classes, marries and begets one child, and after this confinement men- 
struation never returns, the uterus passes into a senile state, and the 
woman's reproductive life is practically over. Here the absence of the 
menstrual function depends on a premature exhaustion of the genital 
system, and on an early exhaustion of the ovary with its Graafian follicle 
system. 

Menorrhagia. — Improved methods of dilatation, and the safety which 



28 SYSTEM OF GYNECOLOGY 

comes from the use of antiseptics, have done much to enlighten us on the 
causation and treatment of uterine haemorrhage. Thus twenty years ago 
comparatively nothing was known of the existence and frequency of 
fungous degeneration of the endometrium ; whereas now the use of the 
curette and digital exploration of the uterine cavity have shown us its 
frequency in cases of endometritis and fibroid tumour. Of late years the 
pathological changes taking place in fibroid tumours have been worked 
out ; their methods of cure by natural processes have been clearly laid 
down, and many points in their treatment have been carefully studied. 
Reference has already been made to the so-called Apostoli treatment ; 
and whatever the measure of its failure in the cure of fibromyoma, there 
can be no doubt that in the menorrhagia depending on the presence of 
a submucous fibroid, this method is a useful addition to our remedies. 

Attention has been paid in late years to the influence of an obstructed 
circulation in the production of uterine haemorrhage. Thus the late Dr. 
Wiltshire pointed out the effects of the early stages of hepatic cirrhosis, 
consequent upon the abuse of alcohol, in keeping up uterine blood loss ; 
here the effect of an impeded portal circulation in preventing easy escape 
of blood from the uterine circulation is well demonstrated, for by cutting 
off the supply of alcohol, and exhibiting remedies which act favourably 
on the portal circulation, the menorrhagia can soon be controlled. 

Again, in the case of an overloaded right heart, due to valvular or 
to pulmonary disease, another mode of production of menorrhagia has 
been shown ; for by the use of means calculated to assist the heart's 
action the uterine disorder is materially relieved and finally cured. In 
the knowledge, moreover, of such drugs as hamamelis and the hydrastis 
Canadensis, we have made valuable additions to our store of uterine 
styptics. 

Dysmenorrhma. — It is a cause for regret that we have made so little 
advance in our knowledge of this common disorder ; still in some respects 
we may claim to have gained a more exact and scientific acquaintance 
with the phenomena of painful menstruation. Dr. Champneys has en- 
deavoured to limit the use of the word pain as applied to dysmenorrhoea, 
and has suggested that it is only correctly used when the suffering is 
clearly due to the genital organs, and falls within the genital sphere. 
Pain due to the pelvic organs is limited above by a line level with the 
iliac crests in front and behind, and by the level of the knees below ; by 
this definition various neuralgias, which are often present during the 
menstrual epoch, are excluded. Tyler Smith and other authorities have 
compared the act of menstruation to a miniature pregnancy ; and I my- 
self, following out this simile, have shown that in a large proportion of 
cases the pain of dysmenorrhoea is due to some morbid condition at the 
OS internum, and that the pain really depends on dilatation of the in- 
ternal OS by uterine contractions under morbid conditions. 

Eef erence has already been made to the fact, that uterine contractions 
are present during menstruation, and that their effect in dilating the 
cervical canal is capable of clinical proof. 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 29 

One form of dysmenorrhoea, distinguislied by the exfoliation of a 
membrane every month, has received special attention from gynaecolo- 
gists ; indeed, the literature of the subject is so extensive, that were its 
value equalled by its bulk, our knowledge of the subject would indeed 
be complete. Much difference of opinion has been expressed on the eti- 
ology and pathology of these membranes ; but the researches of Wyder 
and others seem to point to inflammation as their cause. The thickness 
of the membrane, and the depth of the mucous membrane exfoliated, 
vary greatly ; and the microscopical examination shows a great variety 
of pathological conditions : all these conditions, however, are '• endome- 
tritic." Wyder has remarked upon the presence of certain large oval 
cells, which have a length of from 0*012 to 0*02 mm., and nuclei, whose 
diameter is 0-006 ; or these cells, he says, may be two or three times as 
large. These large cells, he believes, are found only in the decidua of 
pregnancy, either intra or extra-uterine ; and they serve, therefore, to 
distinguish real membranous dysmenorrhoea from early abortions. 

It has been pointed out that it is necessary to distinguish the true 
membrane of membranous dysmenorrhoea from those consisting of fibrin 
or blood-clot, coagulated mucus, casts of the vagina or the bladder, 
foreign bodies, or products of conception. It has been shown by many 
writers that mucosa membranes may be passed for some time without 
the presence of any pain ; and pain may be a marked symptom later. 
Thus it is suggested that, apart from some special sensitiveness of 
the canal of the uterus, pain need not result from the separation and 
passage of the membrane. How unsatisfactory is our treatment of 
membranous dysmenorrhoea may be inferred from a remark which 
Champneys makes use of in his Harveian Lectures. " The treatment 
of membranous dysmenorrhoea certainly is a most unhappy problem ; 
not even pregnancy going to full time cures it." 

There is another pathological condition in which gynaecology has 
made marked progress during the last fifty years, namely, inversio uteri. 
Until the year 1858, cases of inversion of the uterus after labour were 
only cured when the patient came under observation shortly after par- 
turition ; and in too many cases amputation of the inverted organ was 
considered the only available resource. About this date Tyler Smith in 
England, and White in America, recorded cases of slow reduction by taxis 
and elastic pressure. Of late years cures have been so numerous, even 
in cases which have come under treatment several years after the acci- 
dent had happened, that the various instances are hardly thought worthy 
of record. The method of reduction which is in favour at present con- 
sists in the use of Aveling's repositor. The latter instrument was in 
no sense invented by Dr. Aveling, for A^on Siebold employed a reposi- 
tor which consisted of a curved stem surmounted by a fine sponge, the 
whole being held in position by a T bandage. Most of these earlier 
instruments, however, having only one curve on their stem, were liable 
to slip ; whereas in Aveling's repositor there is a double curve (both 
sacral and perineal), pressure is transmitted in the curve of the pelvic 



SYSTEM OF GYNECOLOGY 



axis, and slipping is thus rendered less probable. Of the many other 
plans devised for procuring slow reduction of a chronically inverted 
uterus, few have stood the test of time ; and year by year the Aveling 
repositor becomes increasingly popular in the cure of these difficult and 
dangerous cases. In a few cases the accident does not follow labour, 
but depends on the presence of a fibroid or polypus growing from the 
fundus uteri ; it is in these latter cases that vaginal amputation of the 
mass, without any attempt at reduction, is indicated. 

In the short space available it has been impossible to trace at all 
adequately, or to do justice to much which may be reckoned as devel- 
opment of our science and practice ; but enough has been reviewed to 
show that in every department of gynaecology — in pathology, in bacte- 
riology, in anatomy, clinical medicine, and surgery — marked progress 
has been made ; and if at times advance has been retarded by over-zeal- 
ous enthusiasts, still even to them we are perhaps indebted for the fin- 
ger-posts which point out the roads on which we should not travel. It is 
clear that much of our increased knowledge is due to improved surgery, 
and to say this is again to declare the debt we owe to Sir Joseph Lister. 

Mr. Pearce Gould put the matter very eloquently when, in his recent 
address on the Evolution of Surgery, he said : " Although science knows 
nothing of nationality, and we rejoice in additions to our knowledge, and 
to our powers of combating disease and death, whether it comes to us 
from a French Pasteur, from a Teuton Koch, from our western cousins 
on the other side of the broad Atlantic, or from a son of that Eastern 
Empire now rising above the horizon, we cannot help feeling a special 
pride in the fact, that the name that shines with an unrivalled splen- 
dour on the page of surgical history is that of the Englishman Joseph 
Lister." 

Montagu Handfield- Jones. 



EEFERENCES 

1. Atlee. Ovarian Tumours. — 2. Battey. Gynsecol. Trans. 1876. — 3. Henry 
Bennet, Inflammation of the Uterus, \M^. — 4. Bernutz and Goupil. Archiv Gen. 
1857. — 5. Billroth. Surgical Pathology. — 6. Bourdon. Fluctuating Tumour of True 
Pe/uis, 1841. — 7. Burns. Midioifery. — 8. Calvi. Intrapelvic Phlegmonous Abscess, 
1841.— 9. Churchill. Abscess of Uterine Appendages, lS4:4i. — 10. Clark. Diseases 
of Feinales. — 11. Clay. Obstetinc Surgery. — 12. Cullingworth. Brit. Med. Jour. vol. 
ii. 1893. — 13. Denman. Midioifery. — 14. Doherty. Chronic Inflammation of the 
Uterine Appendages, 1843. — 15. Alban Doran. Address Brit. Med. Assoc. Brit. Med. 
Jowr. Oct. 1893. — 16. /6id. Uterine Surgery . — 11 . Matthews Duncan. Bond. Obstet. 
Soc. vol. xxvii. — 18. Ibid. Parametritis and Perimetritis.— IQ. Ibid. Fecu7idity, Fer- 
tility, and Sterility.— 20. Handfield-Jones. Brit. Med. Jour. 1893. — 21. Hart and 
Barbour. Diseases of Women.— 2.2. Hegar and Kaltenbach. Op. Gyn. — 23. 
Graily Hewitt. Diseases of Women. — 24. Hodge. Diseases Peculiar to Women. — 
25. Keith. Tumours of Abdomen. — 2Q. Kundrat and Engelmann. Strieker's 
Med. Jahrbuch. 1875. — 27. Lebert. Traite des Mai. Cancereuses. — 28. Leopold. 
Arch, fiir Gyndk. Band xi. 1877, Band xxi. 1883.-29. Lever. Pelvic Abscess, 
1844. _* 30. NoNAT. Maladies de V Uterus. — 31. Paget. Surgical Pathology. — 32. 
Priestley. B. M. J. vol. ii. 1895.-33. Sims. Uterine Surgery . — 3^. Stephenson. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 31 

B. M. J. March 1892.— 35. Sutton, Bland. Roy. Med.-Chir. Tranmct. 1889.— 
36. Ibid. Lond. Med. Soc. 1892. — 37. Tait, Lawson. Diseases of TFomen. — 38. 
Thomas. Diseases of Women. — ?>^. Thornton, J. K. " Abdominal Surgery Past and 
Present," Lond. Med. Soc. Transact. 1890.-40. Tilt. Ovarian Inflammation, 1850. 
— '^l.Ibid. Utejnne Therapeutics. — 'i2.YEL,F-EAv. Operative Surgery.— -^o. Virchow. 
Cellular Pathology. — 44. Spencer Wells. Abdominal Tumours.— ^b. Williams. 
Harveian Lectures, 1888.— 46. Ibid. Obst. Soc. Lond.— 41. W^yder. .Irc/i. /. Gyn. 
Band xiii. 1878. 

M. H.-J. 



THE ANATOMY OF THE FEMALE PELVIC OEGANS 

A DESCRiPTiox of the anatomy of the genital organs, for gynaecological 
purposes, should have its own topographical basis ; that is, it should be 
described in relation to the bony pelvis. 

I shall therefore arrange this subject under the following heads: — 
I. The main f)oints in the anatomy of the adult female hony pelvis 
and of the pelvic fioor filling in the pelvic outlet. 
II. The anatomy of part of the outer aspect of the floor — that is, of 
the vidva or external genitals. 

III. The anatomy of the organs and tissues in the substance of the jpelvic 

floor — that is, of the vagina, urethra, and bladder ; rectum and 
anus; connective tissue, blood-vessels, lymphatics, and nerves. 

IV. The anatomy of the organs on the upper aspect of the pelvic floor 

— that is, of the uterus, Fcdlopian tubes, broad ligaments, and 
ovaries ; the pelvic peritoneum. 
V. Theijosition of the organs : their dissection and structured an atomy. 
VI. The surgiccd anatomy. 

VII. The development of the organs. 

This convenient method of considering our subject is open to some 
objections. It might be argued, for instance, that the anus and urethra 
could be considered in other divisions than those in which I have placed 
them. The present arrangement, however, will be found suitable for 
our purpose. 

I. The main points in the anatomy of the Female Bony Pelvis and of the 
Pelvic Floor filling in the outlet. — The brim of the pelvis (Fig. 1) has, 
as its boundaries, from left to right, the promontory, left sacro-iliac 
joint, left ilio-pectineal eminence, symphysis pubis, right ilio-pectineal 
eminence, right sacro-iliac joint, and thus back to the promontory. 

The part of the pelvis above the brim is termed the ''false" pelvis; 
that below the brim is spoken of as the " true " pelvis. It is in the 
true pelvis and in relation to the outlet that the unimpregnated female 
genital organs are placed. 

If the bony pelvis be regarded in sagittal mesial section (Fig. 2), 
we can see the conjugate ; the cavity of the true pelvis, with its inlet, 



32 



SYSTEM OF GYNECOLOGY 



cavity, and outlet ; the inclination of the conjugate to the horizon 
(average of 60°), as well as the outline of the pelvic floor. What of the 







Fig. 1. — Brim of bony pelvis. 



pelvic floor projects beyond the outlet-conjugate is termed the pelvic 
floor projection, and averages, at its utmost, about 3-2 cm. 




Fig. 2. —Diagram of bony jielvis and of pelvic floor. 1, Conjugate; 2, anal axis; 3, 4, vaginal and 
urethral axes; 5, horizontal line ; 6, outlet-conjugate. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



ZZ 



On the outer aspect of tlie pelvic floor lie the external genitals, and 
these in the upright posture have a direction nearly parallel to the 
horizon. 

In the substance of the pelvic floor lie the vagina and urethra, parallel 
to the conjugate, and about 2 J to 3 inches below its level ; the anus with 



PROMONTORY 



FALLOPIAN TU2r_, 



POUCH OF DOUGLAS 



INFUNDICULO-PELVIC 



OVARY 

OVARIAN FIMBRIA 




URETHRA 
CLITORIS 
LABIUM MINUS 



PERINEAL BODY 



Fig. 3. — Sagittal mesial section of female pelvic floor. The ovary is larger than normal, and the tube 

relations not quite normal. 



its long axis at right angles to these ; and resting on the upper surface, 
the peritoneum and the uterus with its appendages (Fig. 3). Dr. Her- 
man gives the following table of clinical measurements : — 



Projection of pelvic floor 

Coccyx to anus 

Fourchette to pubic arch (nuUiparEe 



3-2 cm. 
4-5 cm. 
2-19 cm. 



II. The anatomy of the External Genitals — that is, of part of the 
outer aspect of the pelvic floor. — The external genitals lie on a surface 
extending from the front of the symphysis pubis downwards and back- 



34 



SYSTEM OF GYNAECOLOGY 



wards between the thighs, their posterior boundary, the fourchette, being 
about l-ly inch in front of the anus. They comprise the following 
structures ; namely, the labia majora, labia minora, fourchette, clitoris 
and prepuce, vestibule, urethral orifice, hymen, fossa navicularis. 
The general arrangement of these parts is seen in Figs. 2 and 4. 
It must be noted that in order to see these parts in the living woman 
their mutual relations are necessarily disturbed. It is therefore of im- 
portance to note that, in the undisturbed condition, the labia majora 
and minora, being in contact by their inner surfaces, conceal the deeper 
structures, the minora only projecting slightly beyond the majora ; that 
probably the lateral halves of the vestibule are in apposition ; that tlie 
lateral edges of the fourchette touch, forming a long U, as seen in Fig. 4; 
and that the lateral edges of the hymen are also in contact. 

The lahia majora are two folds of skin, united above over the pubes in 
the mons veneris, which pass downwards and backwards between the 
thighs, gradually thinning off at a point l-J- inch in front of the anus. 
Short crisp hair covers their outer aspect, and microscopically we find 
sweat glands, hair follicles, and the usual constituents of a skin structure. 
The labia minora are also formed of skin of a thin, fine quality ; 
they lie obliquely on the inner aspect of the upper two-thirds of the 
labia majora, and by the bifurcation of their upper ends form the pre- 
puce of the clitoris and its so-called suspensory ligament. 

._ The vestibide is a triangular 

.,.,.--^1 surface of smooth mucous mem- 

I brane covered with several layers 

I of epithelium, lying between 

I the labia minora, and having 

\ the hymen at its base ; the ure- 

thral orifice is in the middle 
of the base line immediately 
above the hymen. In the mid- 
dle line, in the virgin, is a 
grooved ridge which represents 
the corpus spongiosum of the 
male — Pozzi's male vestibular 
band. 

The posterior ends of the 
labia minora form a narrow U- 
shaped loop — the fourchette ; 
if these margins be separated 
we see the fossa navicularis 
as a shallow fossa, artificially 
made by the examination, and 
bounded by the inner aspects 
of the fourchette and outer 
and lower portions of the 
hymen. Between the fourchette and base of the vestibule lies the 



ffl 



Labium majus 

PREPUCE 

CLANS CLIT0RIDI5 

UABIVM MINUS 



FOURCHETTE 



Fig. 4. 



- Virgin external genitals with the 
labia majora separated. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



35 



hymen, the anatomical entrance to the vagina. It consists of a thin fold 
of mucous membrane, perforated, so that ^^hen viewed undisturbed, its 
opening forms a vertical slit with its edges in contact. According to Dr. 
Cullingworth, the hymen is a longitudinal fold of mucous membrane with 
its edge directed forwards, and divided along about three-fourths of 
its length by a slit which extends nearer its upper than its lower 
extremity. The alterations in it induced by coitus and labour belong 
to obstetrics. 

The ancd opening lies about 1\ inch posterior to the fourchette, 
and between the two is the skin over the base of the perineal body 
(Fig. 4). 

The glans of the clitoris covered by its prepuce lies at the apex of 
the vestibule. 

III. The anatomy of the organs and tissues in the substance of 
the pelvic floor — that is, of the Vagina, Urethra, Bladder, Rectum, 
and Anus, Connective Tissue, Blood-Vessels, Lymphatics, and Nerves. 
— The vagina is a transverse slit in the pelvic floor, extending from the 
hymen to the fornices, where it passes on to the outer aspect of the 
vaginal portion of the cervix uteri at the base of the latter ; the de- 
marcation between them being recognisable to the naked eye. 

The vagina lies parallel to the conjugate, and consists of two apposed 
walls, anterior and posterior. Each wall is broader above than below, 
and is therefore somewhat triangular in shape. The mucous membrane 
lining it is thrown into many transverse shallow folds — the rugse of the 
vagina. At the lower end of the posterior wall is one short vertical fold, 
the posterior column of the vagina ; while there are usually two at the 
corresponding portion of the anterior wall — the anterior coin mns of the 
vagina. They are said to represent the remains of the septa between 
the two ducts of Miiller, from part of which the vagina is formed 
(Fig. 3;. 

Between the vaginal portions of the cervix and the reflexions of 
the vaginal walls lie the fornices of the vagina — anterior, lateral, and 
posterior. The anterior is the guide to the loose tissue between the bladder 
and the cervix; the lateral lie at the inner aspects of the bases of the broad 
ligaments, and form a guide to the uterine artery and ureter ; while the 
posterior is separated from the peritoneum of the pouch of Douglas by 
about \ inch of tissue. The walls of the fornices are in contact. 

On sagittal mesial section (Fig. 3) the anterior wall, 2-1- inches long, 
is seen to be straight; the posterior wall, 3^ inches long, bends forward 
at its upper part. 

On transverse section the vagina is crescentic at its upper part, 
H-shaped lower down, and vertical at the hymen. 

Microscopically the hymen has multiple epithelium on its outer and 
inner aspects, the latter being thicker. 

The vagina is lined on its free surface by many layers of squamous 
epithelium ; deeper down near the papillae the epithelium is more oval in 
shape. This epithelium lies on papillae of connective tissue, with elastic 



36 



SYSTEM OF GYNMCOLOGY 



tissue and unstriped muscular fibre. Outside this lie two layers of 
unstriped muscular fibre, an outer (circular) and inner (longitudinal). 
Only a few glands are present in the vagina, which has a structure quite 
homologous to skin. 

It is of great importance to note that loose connective tissue separates 
the anterior rectal wall and the posterior vaginal wall, and lies also 
between the bladder wall and the anterior vaginal wall. The urethra 
and anterior vaginal wall are closely incorporated. 

The urethra forms a slit in the pelvic floor, parallel to the vagina, and 
is in reality a tonically contracted sphincter 1| inch long with the urethral 
orifice below and the bladder-opening above. It is lined with many 
layers of epithelium, squamous below, and like that of the bladder above. 



'^^r'r^.,.,. 



Tagina 




Rectum 



Fig. 5. — Rectal and vaginal mucous membrane. 



It is well provided with elastic tissue and muscle ; for there are not only 
circular and longitudinal unstriped fibres, but the same arrangement of 
striped muscle also. Finally, we should keep in mind that at the meatus 
mucous glands are present as well as villous tufts. Skene's tubules lie at 
the lower end of the floor of the urethra, are two in number, about -| in. 
in length. A very important practical point about the urethra is its 
dilatability. By means of suitable dilators an amount of dilatation can be 
obtained sufficient to admit the ordinary index finger. Over-dilatation, 
however, may cause permanent incontinence. 

With the empty bladder the urethra forms a Y, the anterior limb of 
the Y being the longer. Between the urethra, anterior surface of bladder, 
and the posterior aspect of the pubes is a space, triangular in shape on 
section, containing loose tissue and fat — the retro-pubic fat (Fig. 3). 
The bladder is sometimes seen in the cadaver as a thick-walled, appar- 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 37 

ently contracted organ, with its anterior and posterior walls in contact. 
On sagittal mesial section the cavity then forms a slit continuous with 
the urethra. 

The bladder walls consist of mucous membrane lined with multiple 
and multiform layers of epithelium, and of unstriped muscle in three 
layers ; its fundus alone is covered by peritoneum. The mucous and 
muscular coats are separated by loose tissue. The empty bladder is a 
pelvic organ in the non-pregnant woman. It is generally believed that 
its capacity is greater in women than in men ; and, as a matter of 
fact, many women pass water twice only in the twenty-four hours. 

The ureters, two in number, run between the kidneys and the bladder. 
I shall describe their course in the pelvis only. At the pelvic brim each 
crosses the external iliac artery, and passes down the side wall of the 
pelvis below the level of the fossa ovarii. Where the vesical and obturator 
vessels originate, it begins to describe a bow-shaped curve, the middle por- 
tion of which is crossed by the uterine artery at the level of the os uteri 
externum, from which it is about f inch distant. It here lies related to 
the side of the vagina (Figs. 8 and 19), and then runs between the anterior 
vaginal wall and posterior bladder wall. It finally rims in the substance of 
the bladder wall for about -6 inch, and opens into the bladder cavity. 

If the bladder cavity be laid open we shall see three openings into 
it ; namely, the internal orifice of the bladder in the middle, and a ureteric 
opening at each side. The latter are about \.\ inch from the middle 
line. Between the ureteric ends lies the inter-ureteric ligament. 

The rectum begins at the pelvic brim, and ends at the anus. We 
recognise three portions ; namely, the first part, provided with a meso- 
rectum, beginning at the left sacro-iliac joint, and ending at the third 
sacral vertebra ; the second part, where the peritoneum gradually passes 
off from behind towards the front ; and the third part Ij^ing behind the 
posterior vaginal wall. It is separated from the posterior vaginal wall 
by loose tissue. The microscopical structure of the rectum is perito- 
neum outside ; unstriped muscular fibre in two layers — the longitudinal 
inner, and the circular outer ; and a submucous coat with a mucous mem- 
brane provided with a muscularis mucosae. The mucous membrane is 
provided with abundant Lieberkuhnian follicles. 

There are two important crescentic folds in the rectum, which form 
the sphincter tertius ; they lie, one on the anterior wall, the other on the 
posterior. Each is about 1\ inch from the anus, the posterior being 
the higher. The fold is formed by a special thickening of the circular 
muscles. 

The anus is a closed slit in the pelvic floor with only a slight antero- 
posterior linear measurement. It measures about an inch in length, and 
runs parallel to the axis of the pelvic brim ; that is, at right angles to 
the rectal, vaginal, and urethral axes (Fig. 2). It is provided with a 
strong musculature (Fig. 6); namely, the sphincter externus, and sphincter 
internus, — the latter in two layers, circular (outer) and longitudinal 
(Ruedinger). 



38 



SYSTEM OF GYNECOLOGY 



In front of tlie anus lies the perineal body, its apex being about the 
level of the internal opening of the anus and external orifice of the 
uretha. It is a pyramid of elastic tissue and of striped and unstriped 
muscular fibre. It f onus a bracing pointy therefore, for much of the 
musculature of the pelvic floor ; namely, for sphincter ani, transversus 
perinei, bulbo-cavernosus, and levator ani (Figs. 3, 7, 8, and 9). 




ANAUM.EAy 



Fig. 6. — Sphincter ani in full-time foetus. 



The connective tissue of the female pelvis is very abundant and of great 
importance. It packs all the interstices between the main organs, and is 
of great pathological interest, as in it run the lymphatics, blood-vessels, 
and nerves. Although the pelvic connective tissue is practically continu- 
ous, and passes up into the iliac fossae and abdominal cavity, it is con- 
venient to recognise it as being present in the following situations : — 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



39 



(a) Round the cervix uteri : this is the parametric tissue proper of 
Virchow. (6) Between the broad ligaments, (c) Between the poste- 
rior bladder wall and cervix uteri, (d) Between the vagina and the 
anterior rectal wall, (e) Between the bladder and the pubes. (/) In 
the ischio-rectal fossa and below the peritoneum. 

By some anatomists the term parametric tissue is made equivalent 
to pelvic connective tissue. 



FEMORAL VEIN 




obturat'or INTERNUS 



Fig. 7. — Axial transverse section of right half of female pelvic floor. (Seen from behind.) 



We have also in the pelvic floor an arrangement of sheet fascia — 
the pelvic fascia of the anatomist; the main parts of which can be 
seen in the diagrams of frozen sections (Figs. 7, 8, and 9). 

The blood-vessels of the pelvis consist of arteries and veins. 

The arterial supply of the pelvis is derived from the ovarian and 
uterine arteries. 

The ovarian artery is a branch of the aorta, and passes along the up- 
per border of the broad ligament below the level of the Fallopian tube. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



41 



It gives branclies to tlie tube, ovary, and round ligament ; and then at 
the junction of tube and uterus passes tortuously down the sides of the 
uterus to join the uterine artery. From the arch thus formed at the side 
of the uterus branches pass at right angles into the uterine substance. 
The uterine artery is a branch of the anterior division of the inter- 



SMALL INTESTINE 




CROAD LIGAMENT 



ISCHIORECTAL FOSSA 



Fig. 9. — Axial coronal section of right half of female pelvis. (Seen from behind. : dotted line = fascia.) 



nal iliac. It passes downwards and inwards towards the cervix uteri, 
giving a well-marked branch to the cervix — the circular artery; but 
sometimes several smaller branches take its place. The relation of the 
uterine arteiy to the ureter must be kept in mind. The uterine artery 
also gives branches to the vagina ; and these, with branches from the 
circular artery, form the azygos artery of the vagina. The jpudic artery, 
a branch of the same anterior division of the internal iliac, is a well- 
marked vessel at the outer boundary of the ischio-rectal fossa; and 



42 



SYSTEM OF GYNECOLOGY 



from it we get tlie superficial and transverse perineal arteries, the 
artery to the bulb, corpus spongiosum, and clitoris, and the inferior 
hyemorrhoidal artery (Figs. 10 and 21). 



Blood si//y>^y o/ i/ter^/s f^^r^lj 



Fig. 10. 



OVARIAN ARTERY 




UTERINE AflTERy 



The venous supply of the pelvis consists of many anastomosing plex- 
uses. There are thus vesical, hsemorrhoidal, labial, vaginal, uterine, 




TO LUMBAR GLANDS 



ROUND LIGAMENT 



TO HYPOGASTRIC GLANDS 



Fig. 11. — Lymphatics of uterus. (Poirier.) 

ovarian, and pampiniform plexuses. The vesical, vaginal, hsemorrhoidal, 
and pudic veins open into the internal iliac, and this passes to the infe- 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



43 



rior vena cava. An important point is that the superior hsemorrhoidal 
vein passes to the portal system, and we thus get an anatomical explana- 
tion of the menorrhagia of drunken women. The pelvic veins are un- 
provided with valves. The uterine plexus opens into the ovarian veins ; 
the right ovarian vein passing to the inferior vena cava, where it is 
provided with a valve ; the left to the renal vein. 

The lymplmtics (Figs. 11 and 12) of the pelvis begin in connective 
tissue spaces, form plexuses, and are so arranged that those from definite 
areas pour into definite groups of glands. Thus the Ij-mphatics of the 



EUP. UUM. GLANDS 



INF. LUM. GI-ANCS 




LYMPHATICS OF 
CORPUS UTERI 
LYMPHATICS OF OVARY 



UIAC LYMPH. GLAND 
CERVICAL LYMPH. GLAND 



Lymphatics of uterus and pelvis. (Poirier.) 



external genitals and lower fourth of the vagina pour into the oblique 
inguinal glands ; those of the upper three-fourths of the vagina and cervix 
uteri into the iliac glands. The lymphatics of the body of the uterus 
l^ass along the broad ligaments, and, accompanied by those from the ovary 
and Fallopian tube, reach the lumbar glands. The 13'mphatics of the 
round ligaments open into the inguinal glands, and a gland lying on the 
obturator membrane also establishes a communication between the pelvic 
connective tissue and the inguinal glands. The rectal lymphatics open 
into the sacral glands ; those of the bladder pass to the iliac glands. 



44 



SYSTEM OF GYNECOLOGY 



These facts are of great pathological importance. In malignant 
disease of the vulva and lower fourth of the vagina, the oblique inguinal 
glands are affected; but in cancer higher up, the pelvic and lumbar 
glands are first infiltrated. Through the lyinphatics of the round liga- 
ment, and especially through the obturator gland, we may have, though 
rarely, late infection of the inguinal glands in uterine cancer. I have 
now several times seen the inguinal glands enlarged in pelvic sarcoma, 
and in one instance I found the obturator gland distinctly enlarged. 

The abundant lymphatic supply of the pelvis explains the inflamma- 
tory attacks arising from sepsis and gonorrhoea, and abundant evidence 
of their importance will come up afterwards. Here we can only em- 
phasise the great importance of antiseptics in operative work, and the 




Fig. 13. —Nerve diagram. (Flower.) 

avoidance of all minor manipulations with the sound as a means of 
diagnosis in the consulting-room. 

The 7ierves of the pelvis are spinal and sympathetic. The levator 
and sphincter are innervated by the inferior hsemorrhoidal branch of 
the pudic, and by the fourth and fifth sacral and coccygeal nerves ; the 
coccygeal nerves and fourth and fifth sacral also supply the coccygeus. 
Branches of the pudic nerve pass to the muscles of the perineum and 
clitoris. 

The sympathetic is arranged in many plexuses. The hypogastric 
plexus between the common iliac arteries gives branches which, with 
those from lumbar and sacral ganglia and sacral nerves, make up the 
inferior hypogastric plexuses lying on each side of the vagina. Branches 
from them pass to the vagina, uterus, Falloj)ian tubes, and ovaries. 

Special end bulbs are found in the clitoris and labia minora. In the 
vagina the nerves end in the epithelium. In the uterus, nerve plexuses 
and nerve cells are present in the muscular coat, and the nerve-endings 
can be traced to the glands and epithelium. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



45 



In the tube the nerves are arranged in two concentric plexuses, 
ending in the epithelium and in the nerve cells of the submucosa. In 
the ovary the nerve-endings have been traced to the Graafian follicles 
and cells of the membrana granulosa. 

Pain is so common a gynaecological symptom that it is remarkable 
that gynaecologists have not brought more precision into their descrip- 
tions of it. In a recent paper in Brain, Dr. Head has attempted to give 
greater accuracy to the definition of these sympathetic painful areas ; 
he states that the area for ovarian pain is " limited above by a line run- 
ning horizontally from the top of the first lumbar spine to the umbilicus ; 
below by a line running from the third lumbar spine to midway between 
the pubes and umbilicus, but having a little downward tag near the an- 
terior superior iliac spine." For the body of the uterus and Fallopian 
tubes the area is bounded above by the preceding one ; and below by a 
line running from a little below the top of the sacrum to the symphysis, 
but having a dip down over the buttock, and another over the front of 
the thigh. For the cervix uteri the painful area is over the lower part 
of the sacrum. For the ovary, therefore, it is formed by the sensory fibres 
from the tenth dorsal nerve 

root ; for the body of the \ V-v Xj 

uterus and Fallopian tubes y^~^\ Z'^'*^^ 

by the sensory fibres of the | p\ \ / (fn f 

eleventh and twelfth dor- \ v ) I / / 1 7 

sal nerve roots; and for \\\ | j {{J /j 

the cervix by the sensory r l^ / ^-^ "*'*'"*<>^ / ,^J 

fibres of the third and vlvt^^ ^\:~^— -r^^^^ 

fourth sacral roots. ^^^^^"m.,,,,, m"»"i)^^^^-^^^^^^ 

IV. The anatomy of ""' " " 

the organs on the upper 
aspect of the pelvic floor 
— that is, of the Uterus, Fallopian Tubes, Broad Ligaments, and 
Ovaries ; the Pelvic Peritoneum. (Figs. 14 and 15.) The Uterus. — 
If the uterus be separated from its appendages, it will appear as a 
pear-shaped body with a constriction — the isthmus — slightly below 
its middle, dividing it into two great parts, the body and cervix. At 
its inferior extremity is the os uteri externum ; at the upper right and 
left angles lie the openings of the Fallopian tubes. Its anterior surface 
is more flat than the posterior, and only the upper half of the former 
is covered by the peritoneum. If a vertical mesial section be made, 
we can then see that the uterus has a cavity or slit, that its walls 
are about half an inch thick, and that the cavity is lined by mucous 
membrane -^ inch (1 mm.) thick. In a section through the cavity, 
dividing the uterus into anterior and posterior portions, we can see 
the shape and relations of its cavity more clearly displayed. The cer- 
vical canal is somewhat spindle-shaped, and the so-called uterine 
cavity consists of anterior and posterior triangular surfaces which nor- 
mally, and in the unimpregnated condition, are in apposition. The os 



Fig. 14. — Relations of uterus and ovaries viewed through 
brim. (Ills.) 



46 



SYSTEM OF GYNAECOLOGY 



uteri externum is the lower boundary of the cervical canal ; the upper 
boundary is less definite, but for practical purposes we may place it op- 
posite the isthmus. The os uteri internum is the lower opening of the 
uterine cavity proper, while to the right and left above are the internal 




Fig. 15. — Sagittal lateral section of female pelvis, L points to ischio-rectal fossa. 

openings of the Fallopian tubes. These three points ; namely, the os uteri 
internum and the Fallopian tube openings — map out the normal surface 
from which menstruation takes place, and where normal pregnancy occurs. 
It is difficult to divide the unimpregnated uterus accurately into its 
various parts. If we take the anterior wall of the uterus we may con- 
sider it as made up of three portions : firstly, the cervix, where the blad- 
der is attached, and with the os uteri internum as its upper boundary — 



777^ AjVATOA/V of THE FEMALE PELVIC ORGANS 



47 



the average measurement of this is an inch : secondly, the lower uterine 
segment, which is rudimentary, and is bounded below by the os uterine 
cLANo o^^ internum, and above by the 

firm attachment of the peri- 
toneum — it measures about 
half an inch, and has not 
yet been accurately mapped 
out : thirdly, the body of the 
uterus proper, which begins 
where the peritoneum is 
firmly attached, and extends 
up to the fundus. 

The cervix has been 
divided by some into a vag- 
inal, middle, and supravagi- 
nal portion ; and this division 
is of importance in relation 
to cervical hypertrophies. 
The vaginal portion is the 
symmetrical, unattached part 
of the cervix (Fig. 17) ; the 
middle portion is attached to 
the bladder in front, but is 
free behind ; and the supra- 
vaginal portion is attached to 
the bladder in front and to 
the vagina behind. 

Structure of the Uterus. — 
The outer aspect of the uterus 
is covered by peritoneum, ex- 
cept where the bladder is 
attached. Its wall is half an 
inch thick, and made up of 
unstriped muscular fibre and connective tissue. The mucous membrane 
of the uterus is -j^ of an inch thick 
and merits special description. In 
the cervical canal the mucous mem- 
brane has a peculiar arrangement visi- 
ble to the naked eye — the well-known 
arbor vitse. This consists of a vertical 
ridge with lateral ones slanting up- 
wards and outwards. The cervical mu- 
cous membrane consists of columnar 
epithelium, ciliated and narrow, with 
the nucleus deep in the cell. IMany 
glands of a racemose type are present, 
and penetrate deeply into the connective tissue. 




Fig. 16.- 



Uterine tnncoTis membrane showing relation of 
glands and stroma. 




Fig. it. 



• CerTix and upper part of ragina 
showing rugae. 



In the substance of 



48 SYSTEM OF GYNECOLOGY 

the cervix are dense connective tissue and nnstriped muscular fibre. The 
vaginal portion of the cervix is covered with many laj^ers of squamous 
epithelium continuous with and similar to that of the vagina. The mucous 
membrane of the uterine cavity proper is -^^ of an inch thick, and of a 
grayish red colour : it consists of a surface covering of columnar epithe- 
lium and an embryonic connective tissue. Numerous so-called " glands " 
open on its surf ace, and ramify and intersect in all directions down to the 
muscular coat. There is no submucous connective tissue. The " glands " 
are lined with columnar epithelium of the same nature as the surface 
epithelium, and continuous with it. So far as my observation goes, the 
epithelium does not rest on a membrana propria. There has been much 
discussion as to the nature of these so-called glands : it is best on the 
whole to regard them not as specially glandular, but as mere pits of epi- 
thelium, honey-combing the mucous membrane. The mucous membrane 
is really a lymphatic tissue, reticulated with epithelial diverticula whose 
function in some points we understand. During menstruation there is 
a superficial denudation of the mucous membrane ; and it is from the 
epithelial pits and the connective tissue between them that regeneration 
takes place. During pregnancy also, we have, persisting close to the 
muscular coat, the funduses of these pits in the form of the well-known 
spongy layer. This arrangement permits not only of the separation of 
the placenta and membranes during the third stage of labour, but also 
gives again epithelium and connective tissue for the development of a 
new mucous membrane during the puerperium. The connective tissue 
itself consists of elongated cells with nuclei, and branching small 
round cells anastomosing with one another. Leucocytes when present 
are to be considered pathological j and the same is the case in regard 
to unstriped muscle in the stroma. According to Leopold, the bundles 
of connective tissue are surrounded by endothelial cells, which thus 
form lymph spaces. 

The Fallopian tubes are two in number, and pass out from the right 
and left upper angles of the uterus towards the side of the pelvis in a 
way to be described more fully afterwards. Each is about 10 cm. in 
length, and lies below the upper margin of the broad ligament. They are 
covered by the peritoneum for about five-sixths of their periphery, the 
remaining and lower sixth resting on the connective tissue between the 
layers of the broad ligaments. The following divisions are recognised : 
a portion piercing the wall of the uterus, the interstitial part; a straight 
portion, or isthmus ; a curved portion, the ampulla ; and, finally, the fim- 
briated end, with the special ovarian fimbria. The tube consists of a 
peritoneal covering ; a muscular coat in two layers, circular inner and 
longitudinal outer; and a remarkably folded mucous membrane. The 
mucous membrane lining the tube is continuous with that of the uterus, 
and is thrown into many longitudinal folds which pass out into the fim- 
briated end. In the fimbriated end can be seen the ostium abdominale or 
outer opening of the tube. One special fimbria, the ovarian fimbria, joins 
the ovary and tube. We must note here the remarkable fact that the 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



49 



genital tract of woman communicates by tliis ostium directly with, the 
peritoneal cavity (Figs. 14 and 15). 

The mucous membrane of the Fallopian tube consists of columnar 
epithelium and connective tissue. The foldings of the mucous membrane 
are very much less marked in the isthmus, much more so in the ampulla. 
The question whether these foldings constitute glands is still disputed ; 
but I see no valid reason as yet for considering them as anything more 
than a honey-comb arrangement of the tubal lining, indicating, so far 
as we know at present, its close developmental relation to the uterus. 
The calibre of the isthmus is such as to admit a bristle, while the ampulla 
Avill admit the ordinary uterine sound. 

The tube in the foetus has windings in it of a pathological interest. 
The hydatid of Morgagni, derived from the duct of Mtiller, is attached to 
the fimbriae or tube, and has a mucous columnar lining with clear fluid. 
Muscle and peritoneum make up its head and stalk. It must not be 
confounded Avith cysts in the mesosalpinx arising from Wolffian relics. 

Ovaries. — The ovaries, two in number, lie projecting from the poste- 
rior lamina of the broad ligament, and on the side walls of the pelvis. The 
diameter of each ovary is 1^ inch by J by | of an inch. The posterior 
surface looks backwards, the anterior is attached to the broad ligament; 
their long axis is either perpendicular or somewhat transverse. The 
part of the ovary joining the broad ligament is named the hilum. 

Structure of the Ovary. — The ovary is covered on its outer aspect by 
columnar epithelium, the germ 
epithelium of Waldej'er, who 
first indicated its nature and 
im portance in develop ment. At 
the hilum the germ epithelium 
is continuous with the squa- 
mous epithelium of the broad 
ligament, the boundary being 
marked by the well-known 
white line of Farre. In fresh 
specimens the ovary has a dull, 
pearly lustre, the broad liga- 
ments being more grayish. 
While Farre drew attention to this line of demarcation, he unfortunately 
omitted to note the real nature of the covering of the ovary, a mistake 
readily made if he examined adult ovaries only. 

Below the germ epithelium lies the tunica albuginea, a condensed 
concentric arrangement of connective tissue. On section we see that 
the rest of the ovary is made up of two portions, a cortical or outer zone, 
and a medullary or vascular zone continuous with the tissue of the broad 
ligament. In the cortical portion, and surrounded by connective tissue, 
we have the remarkable structures known as the Graafian follicles. Each 
ovary contains a very large number of these follicles, but whether they 
amount to eighty or ninety thousand, as some authors allege, is not quite 




Fig. 18. — Seal's ovary showing cortical and medullary 
layers, also peritoneal capsule with tube on section. 



50 



SYSTEM OF GYNECOLOGY 



certain. The Graafian follicles near the surface of the ovary are small, 
the larger ones being deeper ; but a few of the largest lie at the periphery. 
Each Graafian follicle consists of a tunica fibrosa and a tunica propria, 
the so-called membrana granulosa, lined with columnar cells and con- 
taining the liquor folliculi. Usually the membrana granulosa has a 
projection of cells, the discus proligerus, which contains the ovum 
proper. The ovum is made up of zona pellucida, yelk, germinal vesicle, 
and germinal spot (nucleus and nucleolus). The columnar cells im- 
mediately surrounding the ovum form the corona radiata. The fresh 




FtG. 19. — Sagittal lateral section of genital organs in 3| months' foetus. Note proximity of rectal and 
broad ligament connective tissue ; the relations of ureter, ovary, and uterine artery are the same 
in the adult. 



nucleolus has been noted to have amoeboid movements. The ovary lies 
in a shallow depression of peritoneum, the fossa ovarii. In some of the 
lower animals, such as the rat and seal, the ovary is surrounded by 
peritoneal capsule, and thus is shut off from the general peritoneal cavity. 
It is alleged that the same arrangement may occur in the human female, 
and be a source of tubo-ovarian cysts (Bland Sutton). The connective 
tissue consists of round cells, and at the hilum are many blood-vessels. 

Pelvic Peritoneum. — The upper aspect of the pelvic floor, the uterus, 
and its appendages are covered by peritoneum, the arrangement of which 
must now be described. 

On sagittal mesial section the arrangement is as follows, from before 
backwards : — The peritoneum of the anterior abdominal wall is reflected 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 51 

on the fundus of the bladder a little above the level of the pubes. It 
then passes on to the anterior surface of the uterus, about the level of the 
OS internum, over the fundus, and down the posterior wall of the uterus, 
which it covers completely. It dips down on the uppermost half inch of 
the posterior vaginal wall, and finally becomes reflected upon the sacrum 
and rectum. The vesico-uterine pouch of peritoneum lies between the 
bladder and uterine wall. The posterior dip of the peritoneum below the 
level of the isthmus is known as the pouch of Douglas ; it will be more 
fully described shortly. The vesico-uterine pouch has sometimes been 
erroneously termed the space of Eetzius (Figs. 3 and 7). 

The broad ligaments are formed by two folds of peritoneum passing 
out from the sides of the uterus to the side wall of the pelvis. The 
anterior fold of the broad ligament is a continuation of the peritoneum on 
the anterior surface of the uterus. Beneath it lies the well-known round 
ligament, which passes from the junction of the Fallopian tube and 
uterus, forwards and outwards to the inguinal canal. These round 
ligaments contain striped and unstriped muscular fibre, blood-vessels, and 
nerves. The posterior lamina of the broad ligament is in the same way 
a prolongation outwards and backwards of the peritoneum on the posterior 
surface of the uterus. It is larger than the anterior lamina, and lies 
partly on the side wall of the pelvis. Thus the ovary comes to lie both 
on the posterior aspect of the broad ligament and on the side wall of 
the pelvis. Between the layers of the broad ligament lie connective 
tissue, blood-vessels, lymphatics and nerves ; the connective tissue passing 
up into that of the iliac fossa. The so-called ovarian ligament joins the 
lower end of the ovary and the angle between tube and uterus ; the 
uterine muscle passes into it. The Fallopian tube occupies the greater 
part of the top of the broad ligament. The infundibulo-pelvic ligament 
of the ovary is that part of the top of the broad ligament not occupied by 
Fallopian tube, and to a certain extent it suspends the ovary. The paro- 
varium also lies between the layers of the broad ligament near the ampulla, 
and consists of a single longitudinal tube with several vertical ones. It 
represents the remains of the Wolffian duct and body, and will be more 
particularly alluded to afterwards. The utero-sacral folds are two ridges 
of peritoneum enclosing muscular fibre and connective tissue ; they pass 
one from each side of the isthmus uteri, outwards and backwards towards 
the second and third sacral vertebrae. The pouch of Douglas can now be 
more accurately defined. Its upper lateral limits are the utero-sacral 
folds ; in front the isthmus forms the anterior boundary, behind is the 
peritoneum covering the sacrum and rectum. The fact that so many 
pathological products are found in the pouch of Douglas, or its neigh- 
bourhood, is to be explained not only by its affording an actual pouch 
for lodgment, but by the near presence of the ovary ; and above all by 
the fact that the openings of the Fallopian tubes lie posterior to the 
broad ligament. Between the utero-sacral fold and the broad ligament 
lie the lateral pouches of Douglas, while on each side of the bladder 
there is a para-vesical pouch. 



52 



SYSTEM OF GYNECOLOGY 



V. The Position of the Organs : their dissection and structural 
anatomy. — The position of the organs is best ascertained and described 
in an adult pelvis which has been hardened and the superjacent intestine 




41^ 


.\ 


\ 


-^ , . A _j " J. rS 




■ 1 




I2^< 1 




1 








~r- ' 


■ f 





carefully removed. One of the best of these drawings has been recently 
published by Waldeyer (Fig. 20). The uterus\\Q^ below the level of the 
brim, usually to the one side, and is anteverted and anteflexed. Viewed 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 53 

from above, therefore, one can only see its fundus and posterior surface. 
The anterior surface touches the bladder, so that the vesico-uterine pouch 
is usually empty. The normal uterus is perfectly mobile, and its shape 
and normal relation to the vagina is a developmental one. Those who 
advocate ventro-fixations seem to forget entirely that the uterus is a 
mobile pelvic organ, and that after such operations it lies for a time in 
a state of abnormal position and fixation. 

The Fallopian tubes pass, firstly, out towards the side of the pelvis ; 
they then turn up, and the fimbriated end becomes applied to the pos- 
terior aspect of the ovary. 

The ovary lies on the posterior lamina of the broad ligament, on the 
side wall of the pelvis, below the level of the brim, and in front of the 
sacro-iliac joint. The ovary on the side of the pelvis to which the uterus 
is inclined has its long axis vertical (Fig. 14) ; the other ovary has its 
long axis more or less transverse. 

The vagina runs through the pelvic floor parallel to the conjugate. 
The part of the rectum in relation to the vagina and to the urethra is 
also parallel to the conjugate. The long axis of the anus is parallel to 
the axis of the pelvic brim. The external genitals in the upright 
posture make a small angle with the horizon. 

Dissection of the Pelvis. — If a cadaver be placed in the lithotomy 
posture a dissection may be made over the rectal portion of the peri- 
neum, and also of the anterior urethral portion. When in the former 
case the skin is suitably removed, we come upon the superficial fascia 
with much fat, and the base of the ischio-rectal fossae. If the fat, super- 
ficial vessels, and nerves be removed from these we then see that each 
fossa is bounded on the inside by the levator ani, and on the outside by 
part of the obturator internus. The varying portion of these boundaries 
is best seen on section (Figs. 7, 8, 9). Between them, the sphincter ex- 
ternus can be dissected out. The pudic artery lies on the inner aspect 
of the ischial tuberosity. If the skin be now removed from the anterior 
urethral portion we come first upon the superficial fascia, and then on 
the deep layer of the superficial fascia. This latter is attached to the 
pubic arch, its base hooking round the trans versi perinei to join the an- 
terior layer of the triangular ligament. On its removal we now see a 
double triangular arrangement of muscles, one on each side of the middle 
line. The base of each triangle is formed by the transversus perinei, the 
outer side by the erector clitoridis, the inner by the bulbo-cavernosus or 
sphincter vaginae. Below the lower end of the bulbo-cavernosus lies 
the Bartholinian gland with its duct opening at the sides of the hymen. 
Higher than the Bartholinian glands, and still below the bulbo-caverno- 
sus, lie the erectile structures known as the bulbi vaginae. The removal 
of these muscles now exposes the anterior layer of the triangular liga- 
ment. This layer having been dissected off, we come upon the terminal 
branches of the pudic vessels and nerves lying on the posterior layer, 
and then cut into the retro-pubic fat. The exact relations of the fascia 
here have not yet, however, been accurately worked out. The triangular 



54 



SYSTEM OF GYNECOLOGY 



ligament undoubtedly acts as a supporting element to the urethra and va- 
gina, which perforate it ; and in the rare cases where a nullipara suffers 
from prolapsus uteri the edge of the triangular ligament, where it is 
perforated by the vagina, can be felt like a ring (Fig. 21). 




Fig. 21. — Perineal region. 



If a dissection be now made from above, and the peritoneum, uterus, 
and appendages removed, the pelvic diaphragmatic muscles will be ex- 
posed. These are the coccygei and the levatores ani ; and viewed from 
above they form a concave muscular arrangement. The levator ani has its 
origin from the posterior aspect of the pubes, from the white line of fascia. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



55 



and the ischial spine. The fibres pass down, almost vertically, to become 
attached to the vagina, the rectum, its fellow, and the tip of the coccyx. 

The coccygeus has its origin from the spine of the ischium and passes 
to the lower part of the sacrum and front and side of coccyx. 

The obturator internus is well seen in the sections (Figs. 7, 8, 9). 

Structural Anatomy. — In sagittal mesial section the pelvic floor is an 
unbroken layer. The vagina and 
urethra do not impair its strength, 
as they are slits passing through 
it at right angles to the direction 
of intra-abdominal pressure. The 
floor, however, can be divided 
into two portions, — an anterior 
pubic mobile segment, and a 
posterior more fixed or sacral 
segment. The vagina thus forms 
a boundary between these two. 
The pubic segment consists of 
bladder, urethra, and anterior 
vaginal wall. Its mobility is 
due not only to the less firm nat- 
ure of its tissue, but also to its 
loose attachment to the pubes. 

The sacral segment is firmly 
attached to the sacrum, and con- 
sists of the tissue behind the 
posterior vaginal wall, which is 
included in it. In the upright 
posture the sacral segment is the 
supporting one, intra-abdominal 
pressure pressing the pubic seg- 
ment against it. 

Changes in pelvic floor due to posture. — In the position known as the 
genu-pectoral the abdominal bulge lessens at the pubes and increases 
near the diaphragm. The projection of the pelvic floor is also less 
marked ; but the pelvic floor is still unbroken. The following facts are 
now of great importance : — If the edges of the hymen be separated, air 
passes in and the vaginal slit becomes a cavity. The uterus if ante- 
verted previously becomes more so, and lies farther from the vaginal 
orifice. The retroverted unfixed uterus does not become anteverted when 
a patient assumes the genu-pectoral posture, and air is admitted into the 
vagina; but the uterus lies farther from the vaginal orifice and becomes 
more retroverted. These facts as to the dilatation of the vagina by 
posture give the key to proper specular examination, as was first shown 
by Marion Sims. The same dilatation of the vagina can be attained in 
the position known as Sims' semiprone posture, and also in the lithotomy 
posture, especially if the hips be raised. These postural methods are also 




Fig. 22. — Sacral section of pelvic floor. 



56 



SYSTEM OF GYNECOLOGY 



invaluable in rectal and vesical examination. In the same way the 
rectum can be ballooned, and also, as Kelly has shown, the bladder.^ 
In this way, and by simple specula, thorough visual, and, in certain 
cases, digital examination of the bladder, vagina, and rectum can be 
made ; as will be fully explained in the appropriate section. In exam- 
ination of bladder cases the genu-pectoral posture is advantageous, as 
well as in reposition of the gravid retroverted uterus. 

VI. Surgical Anatomy. — In operative pelvic surgery by the vaginal 
route the following points must specially be kept in mind: — 

i. The posture of the patient and the mobility of the uterus. — There 
is no doubt that the lithotomy posture is the most convenient 
for all operative work. By means of a broad, short, modified Sims' 
speculum the vagina becomes dilated in this posture ; and then with 




Fig. 



■Diagram of genu-pectoral postm-e showing vaginal distension. (Based on frozen section.) 



the volsella the uterus can in most instances be safely drawn near the 
vaginal orifice, and an accessible field of operation thus obtained. By 
most operators the use of the semiprone posture has been abandoned 
for the more convenient lithotomy one. 

ii. Blood-supply : Lines of loose connective tissue in the pelvis allowing 
the separability of the organs. — In the flap operations on the perineum, 
now so generally adopted, the loss of blood is trifling. The bleeding 
is mainly venous, and is readily checked by pressure. In making 
the usual perineal incision with scissors it is advantageous to have the 
thighs well flexed on the abdomen, so as to render the parts tense. In 
suturing, the flexion should be less marked. 

The lines of loose tissue in the pelvis are of the greatest importance 
from an operative point of view. Thus if a transverse incision be made 
over the base of the perineal body, so as to split it into anterior and 
posterior parts, the finger can then pass into the loose tissue between the 
anterior rectal wall and posterior vaginal wall ; and these can be easily 

1 Pawlik of Prague claims priority in this. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 57 

separated till the peritoneum of the pouch of Douglas is reached. In 
this way dermoids of the recto-vaginal septum have been enucleated, and 
also certain forms of deeply burrowing extraperitoneal gestation attacked. 
This route is one seldom followed, but it is worthy of being kept in mind. 
The loose union between rectum and vagina allows of posterior col- 
porraphy operations. The operator can make a vertical mesial incision 
on the posterior vaginal wall until the loose tissue is reached ; he can 
then separate laterally, with the handle of his knife, the posterior 
vaginal wall, remove what seems necessary, and suture. I must also 
point out that this loose union between anterior rectal and posterior 
vaginal wall is an important factor in allowing prolapse of the uterus. In 
the same way the loose tissue between the bladder wall and the upper 
portion of the anterior vaginal wall allows of anterior colporraphy. 

In vaginal hysterectomy the operator readily cuts by a transverse 
incision through the posterior fornix into the pouch of Douglas, as 
the thickness of tissue here is only \ inch. Anteriorly a transverse 
incision in the vaginal fornix exposes the loose tissue between the 
bladder and cervix, and the vesico-uterine pouch can soon be opened. 
Here as a rule little bleeding arises, but it is quite otlierwise with the 
lateral attachments of the cervix; there the tissue is dense and 
abundantly vascularised by the uterine artery. Before cutting the 
lateral attachments, therefore, it is imperative for the operator either 
to ligature or to apply pressure forceps: the anatomy of the ureter 
must also be kept in mind, as there is less than f inch between it 
and the cervix uteri. When once the firm lateral attachments of the 
cervix have been thus sej^arated the uterus can be more thoroughly 
drawn down, and the broad ligaments secured in the same way as in the 
case of the lower lateral attachments. 

Operations on the upper part of the vulva are usually superficial, as 
in clipping away irritable skin in pruritus vulvae. The bleeding is usu- 
ally insignificant, even if the glans clitoridis be cut off. The operator 
must beware of cutting below the apex or sides of the pudic arch. 

In abdominal surgery the anatomy of the incision in the linea alba 
needs no rem ark. In pelvic adhesions the operator must be specially careful 
in the neighbourhood of the sacro-iliac joint and side of the pelvis owing to 
the position of the ureter here, and to the proximity of the large iliac vessels. 

Recently Diihrssen and Martin have recommended in certain cases, 
instead of abdominal section, incision by way of the loose tissue between 
the bladder and the uterus. 

VII. Development of the Organs. — The subject of the development 
of the female genital organs is too complex to admit of full consideration 
here, and I shall therefore only take up some points of practical impor- 
tance. In a human foetus of about the sixth week an important stage is 
displayed. This can be well seen in the diagrams obtained in a foetus 
carefully prepared in transverse serial section by my former assistant. Dr. 
Gulland. The foetus was obtained from a case of extirpation of a six 
weeks' pregnancy, where cancer of the cervix was present ; it was thus 



58 



SYSTEM OF GYNECOLOGY 



perfectly fresh and in all respects normal. In the diagram of the 
transverse section of the abdominal cavity are seen the two Wolffian 




bodies, markedly developed (Fig. 25). Lower down (Fig. 26) they have 
diminished in size, and are represented only by a few tubules ; while the 
ovary, pedunculated and with well-marked germ epithelium covering it. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



59 



can be noted (Figs. 26 and 28). The broad ligaments with the duct of 
Mliller can also be seen. 

Lower down in the pelvis the genital cord is displayed (Fig. 27) ; 



WOLFFIAN BODY 




WOLFFIAN BODY 



Fig. 25. — T. S. of Wolflfian bodies in six weeks' foetus. 

and at this stage one can note three canals in it ; the centre one being 
formed by the coalesced ducts of Mliller, while each lateral one is the 
Wolffian duct. This agrees, therefore, with the usual statement that in 



WOLFFIAN BODY '>^ 




OUCT Of 

■,yy MULUER 

-•^X^A BLADDER 



Fig. 26. — T. S. pelvis, six \A'eeks' foetus. Note wide transverse of pelvis. 

the early foetus there are two sets of organs — the Wolffian bodies with 
their ducts, and the ducts of Mliller. The former atrophy in the female 
sex but leave their traces in the broad ligaments, where are normally found 
the parovarium, or epoophoron (Fig. 28), and also certain additional but 



6o 



SYSTEM OF GYNECOLOGY 



occasional relics in the form of tubules at the hilum, or of a special 
tube in the broad ligament, uterus, or vagina, rarely continuous in all 



SPINAL CORD 



DUCTS OF MULLER 

AND AT SIDE 
WOUFFIAN DUCTS 




Fig. 27. — T. 
sinus. 



S. of six weeks' foetus showing genital cord, a points to tissue in front of urino-genital 
On the posterior wall of the sinus is the eminence where the ducts of Miiller end. 




:••••■•- ••.•".0'--"v' 



of them, known as Gartner's canal. It represents the Wolffian duct, 

and may be a source of retention cyst 
in the localities already named; it is 
normally present in the cow and sow. 
The ovary develops as an epithelial 
thickening on the Wolffian body. The 
outer cells of the ovary form the germ 
epithelium of Waldeyer, which, by 
sending prolongations into the sub- 
stance of the ovary, forms the ova. 

The ducts of Miiller give rise to 
the Fallopian tubes, uterus, and vagina. 
They remain separate to form the tubes, 
and coalesce to form the uterus and 
vagina. Disturbance in this normal 
coalescence gives rise to malformations. According to some anato- 
mists, the Wolffian ducts enter into the formation of the vagina, and 
give rise to the H-shape on transverse section. As the diagram shows, 
the ducts of Miiller forming the vagina at first have a lumen ; but by 
epithelial proliferation from the Wolffian bulbs they become solid. At 



r 



Fig. 2S. — Section of ovary and Wolffian body, 
human embryo, third month. (Nagel.) 
md, Duct of Miiller, par, paroophoron; 
epo, epoophoron (that is, parovarium). 



mm Wf^j}mmw0 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



the lower part of the vagina there develop about the third and a half 
month two special oval epithelial proliferations, which break down cen- 
trally and thus form the hymen (Fig. 29). These bulbs I have recently 
found to be developed from the Wolffian ducts, and I have termed them 



UTERINE CAVITY 




VAGIMA ( NO LUMEN J 



Fig. 29. — L. S. of 85 months' foetus to show development of hymen. This shows formation of hymen 
by development of two bulbs from Wolffian ducts : these join and break down in the centre, and 
are met by an involution of hypoblast below. 

the Wolffian bulbs. This figure also shows the involution of the deeper 
layers of the vestibule to meet the hymen. About the fourth or fifth 
month the solid vaginal proliferation flattens out, and then forms a 
lumen. I believe, however, that it may do so earlier (Figs. 27 and 29). 

In the early foetus (fifth to sixth week) a cloaca is present ; the 
Wolffian ducts open into the urino-genital sinus (Fig. 27) up till the 
third month, when they are closed by the development of the hymen. 
The subsequent stages are the formation of a septum and the develop- 
ment of the clitoris in front, and labia at the sides. 

The relation of the pelvic organs to the germinal layers is of interest. 



62 



SYSTEM OF GYNECOLOGY 



The uterus, tubes, and ovary are mesoblastic ; the adult vagina has its 
lining derived from the epiblast, the lower involution from the local 
outer covering, but the lining above the outer aspect of the hymen is 
furnished, as an examination of my specimens seems to me to demon- 
strate, through the Wolfiian duct. The Wolffian duct is really epiblastic 
in its origin. The anus is also epiblastic, while the bladder and rectum 
are hypoblastic. The vestibule is derived from the urino-genital sinus, 
and is hypoblastic. 

The main practical points resulting from this development are as 
follows : — 




Fig. 30, — Diagram of developing and fully formed genital tract. Ota, Ostium tubae abdominale; Tim, 
hydatis Morgagni ; fo, ovarian fimbria ; o, ovary ; lo, ovarian ligament ; jpo, parovarium ; Ir, round 
ligament ; vg, vagina ; wv, upper wall of vestibule ; cc, corpus cavernosum clitoridis ; u, ureter ; I, 
labium minus ; Zm, labium majus ; wb. Wolffian body. On the right side are seen the normal 
organs, on the left the Wolffian-body relics and duct in addition. (Coblenz.) 

1. Normally in the adult woman we find traces of the Wolffian 
body and duct in the parovarium (Fig. 30). This is the source of the 
ordinary parovarian tumour. 

2. Skene's tubules in the urethra are probably not Wolffian relics, 
but represent the glands of the male prostate. 

3. Abnormal relics of the Wolffian body at the hilum of the ovary, 
and in the broad ligaments, may give rise to papillomatous develop- 
ments. Some authors, however, consider the germ epithelium as more 
probably the source of these when they are present in the ovary. 

4. Gartner's canal may give rise to broad ligament, uterine, and 
vaginal cysts. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 63 

5. Malformations are really due to persistent stages of arrested 
development. 

D. Bekry Hart. 
REFERENCES 

The following references do not represent Gynaecological Anatomy, but merely the 
main sources used in this sketch. Fuller sources are indicated, and should be con- 
sulted when necessary. 

1. CuLLiNGWORTH. " A Note On the Anatomy of the Hymen and that of the 
Posterior Commissure of the Vulva," Jour, of Anat. and Phys. vol. xxvii. p. 343. — 2. 
Farre. "Uterus and its Appendages," Encyc. of Anat. and Phys. vol. v. Suppt, — 
3. Flower. Nerves of the Human Body. London, 1872. — 4. Frankenhaeuser. Die 
Nerven der Gehaermutter. Jena, 1867. — 5. Gawronsky, V. " Ueber Verbreitung und 
Endigung der Nerven in den weiblichen (Jenitalien," Arch, fur Gyn. Bd. xlvii. S. 271. 
— 6. Hart. Atlas of Female Pelvic Anatomy . Edin. 1884. — 7. Ihid. Contributions 
to the Sectional Anatomy of the Fetnale Pelvis. Edin. 1885. — 8. Head. "On Dis- 
turbance of Sensation with Special Reference to the Pain of Visceral Disease," Brain, 
1893. — 9. Herman. "A Contribution to the Anatomy of the Pelvic Floor," Trans. 
Lond. Obst. Soc. vol. xxxi. — 10. Henke. Topographische Anatomie des Menschen. 
Berlin, 1879. — 11. Hyrtl. Die Corrosions Anatomie und ihre Ergebnisse. Wien, 
1873. — 12. Klein. "Entstehung des Hymen," Festschrift der Gesellschaft fiir Geb. 
und Gyn. in Berlin. Wien, 1894. — 13. Minot. Human Embryology. New York, 
1892. — 14 Sutton, J. B. Surgical Diseases of Ovary. London and New York. — 15. 
Waldeyer. Beitrdge zur Kenntniss der Lage der xoeiblichen Beckenorgane. Bonn, 
1892. For a fuller record of literature see Hart's Atlas and Index Medicus. 

D. B. H. 



MALFOKMATIONS OF THE GEIS^ITAL ORGANS IN WOMAN 

Introduction. — The malformations of the female genital organs form a 
natural and sharply defined group of deformities whose special interest, 
from the gynaecological standpoint, lies in the effects which they produce 
upon the menstrual phenomena, and upon the sexual and reproductive 
life of the woman in whom they exist. These effects vary greatly in 
importance with the nature, position, and extent' of the malformation; 
and also, doubtless, with the constitution of the patient and her condi- 
tion as regards marriage. Manifestly the absence of the uterus is a 
more serious matter than the imperfect development of an ovary or a 
tube ; and malformations which are of grave import in a married woman 
may exist without inconvenience in a spinster. 

It will be convenient to consider, first, the malformations of indi- 
vidual organs, beginning with those of the ovaries, and dealing in turn 
with the Fallopian tubes, uterus, vagina, and vulva ; I shall then dis- 
cuss the abnormalities which affect more than one of the reproductive 
organs, including cases of " hermaphroditism." 

In studying these genital anomalies, it must not be forgotten that 
we are concerned with organs which are derived from at least three 
distinct sets of embryonic structures. As embryology is the true key 
to the understanding of the nature of malformations, it will be well to 
state shortly what these organs and structures are. 



64 SYSTEM OF GYNECOLOGY 

Development of the Female Genital Organs. — i. The Ovaries. 

— In the early, sexually indifferent embryo a development of certain 
cells of the genital fold or ridge takes place on each side of the 
vertebral column in the lumbar region. These cells of the germinal 
epithelium, for that is the name given to the epithelium of the peri- 
toneum in this region, form the genital or sexual glands which develop 
at a later stage into the ovaries in the female and the testicles in the 
male. Only a part, however, of the genital gland is thus produced. 
In the female this part of the ovary contains the ova, and is called the 
oophoron ; the other portion, the paroophoron or tubulif erous portion, 
has a different origin. In the early embryo there is seen, lying to the 
outer side of the genital fold, a glandular mass — the mesonephros or 
Wolffian body, with a duct — the segmental or Wolffian duct. In the 
male, some of the tubules of the Wolffian body extend into the genital 
gland, and form the rete testis, others remain as the vasa efferentia, 
whilst the Wolffian duct becomes the epididymis and vas deferens. In 
the female the Wolffian body largely atrophies ; still, just as in the 
male, some of its tubules enter into the genital gland, and form the par- 
oophoron, whilst others, along with the Wolffian duct, persist in a rudi- 
mentary state as the parovarium or epoophoron, and occasionally as 
Gartner's duct.-^ At a later stage in development the sexual glands 
descend from their primitive position, the testicles passing to the scro- 
tum, and the ovaries to the brim of the true pelvis. Such is the com- 
position and development of the ovary ; and the anomalies which may 
be expected are, therefore, malposition or non-descent of the whole 
organ, and abnormalities by excess or defect of either or both its con- 
stituent parts, oophoron and paroophoron. 

2. The Fallopian Tubes, Uterus, and Vagina are the representatives 
of the two Miillerian ducts of the embryo. Lying near the Wolffian 
body, and on the outer side of the Wolffian duct, the Miillerian duct, 
which is at first a solid cord, passes downwards to open into the allan- 
toic portion of the cloaca. At a later stage the duct acquires a lumen, 
and later still it fuses, in its lower portion, with its fellow of the oppo- 
site side to form the uterus and vagina, whilst its upper part remains 
separate as the Fallopian tube. In the male foetus the Miillerian ducts 
atrophy almost entirely, and are represented only by the uterus mascu- 
linus or prostatic vesicle, and possibly by the true hydatid of Morgagni. 
The anomalies that may be expected in connection with these organs in 
the female are irregularities in the fusion of the lower parts of the 
Miillerian ducts, in their mode of termination, their partial or complete 
absence, and their imperforate condition. As Avill be seen later, all these 
malformations (that is, double uterus and vagina, uterus unicornis, atresia 
and defectus uteri et vaginae, and so forth), and others which are not so 
easily explained by the help of embryology, are comparatively common. 

3. The Vulva. — The mode of development of the external organs of 
generation is more complicated than, and not so well understood as that 

1 For further information on the homologies of these structures, see (1) . 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 65 

of the vagina and uterus with its annexa. At the posterior or lower end 
of the embryo an invagination of the ectoderm occurs, by which the 
cloaca is brought into communication with the exterior, and thus is 
formed the cloacal opening or primitive anus. This is followed by an 
indifferent stage, during which it is impossible to foretell the sex of the 
embryo. The anterior part of the anal plate becomes thickened, and 
gives rise to a projection known as the genital tubercle, which is the an- 
lage of the penis in the male, and of the clitoris and nymphae in the 
female. In its indifLcrent stage it may be termed the phallus. On the 
under surface of the genital tubercle appears a groove — the genital 
groove — which passes backwards into the cloaca. In the female the 
lips of this furrow become the labia minora, and the integument outside 
them develops into the labia majora. Soon the cloaca is seen to be 
divided by a partition — the future perineum — into an anterior cavity, 
or uro-genital sinus, into which open the urinary and sexual ducts, and 
a posterior which opens at the permanent anus. In the female the 
genital tubercle remains small and imperforate, and the sinus urogeni- 
talis persists as the vestibule into which opens the urethra (the drawn- 
out lower end of the allantois), and the vagina with its hymeneal fold. 

From what has been said of the development of the external genitals, 
complicated as it is with that of the lower end of the bowel and uro- 
genital ducts, it is not difficult to understand how many puzzling anoma- 
lies may arise, — anomalies which have led to errors in the determination 
of the sex of the infant at birth, and to most unhappy consequences in 
later life. One is, therefore, prepared to find that the principal mal- 
formation of the external genitals is that known as hermaphroditism, 
or by the better name of pseudo-hermaphroditism. 

The mode of development of the generative organs must be constantly 
borne in mind in the study of the malformations to which they are sub- 
ject ; for many of these are thus at once capable of explanation. Cer- 
tain anomalies, it is true, admit of no such easy elucidation; nevertheless 
it is probable that a more exact knowledge of the early stages of devel- 
opment, when obtained, will serve to clear up what is at present obscure. 
The primary etiological factor which interferes with, and arrests the 
development of the internal genital organs, may with some confidence 
be supposed to be foetal peritonitis. The malformations of the external 
parts may, on the other hand, be due to amniotic compression or adhesion. 

Malformatioxs of the Ovaries. — It is only within recent years 
that special attention has been paid to ovarian anomalies, yet these dis- 
orders affect the sexual life and responsibilities of the woman, and may in- 
terfere with the success of such operations as oophorectomy or ovariotomy. 

Pathology. — 1. Supernumerary Ovaries. — It is well to reserve the 
term " supernumerary ovary " for such rare cases as that reported by 
Winckel, in which a third ovary lay in front of the uterus, to which it 
was attached by a strong ovarian ligament. It also formed connections 
with the bladder and with the right Fallopian tube. The two normal 

F 



66 SYSTEM OF GYNECOLOGY 

ovaries were of equal size, and there were no traces of peritonitis in 
their neighbourhood. The supernumerary ovary was twice the natu- 
ral size. The patient, an old woman, was sterile, notwithstanding the 
abundance of ovarian tissue. No case exactly resembling Winckel's 
has yet been recorded, and the condition must be very rare. Embry- 
ology gives little help in solving its mode of origin. It may have been 
due to duplication of the sexual gland on one side ; but Winckel sug- 
gests that it was developed from the anlage of the bladder (allantois), 
and that in this way its vesical attachment is explicable. 

2. Accessory or Constricted Ovaries. — Accessory ovaries differ greatly 
from the anomaly which has just been described. They are much less 
rare, for they are found in from two to three per cent of autopsies ; they 
are rounded bodies always smaller than the normal ovary, to which they 
have a pediculated, rarely a sessile attachment near its peritoneal bor- 
der, and they vary in number from one to three. In a case observed by 
J. D. Williams, and seen by myself, the accessory ovary was of the size 
of a large pea ; it was made up of ovarian stroma with Graafian folli- 
cles, and was attached to the anterior border of the right ovary by a 
stalk which consisted partly of fibrous tissue, with an external coating 
of low cubical epithelium, and partly of solid columns of epithelial cells 
enclosed in the fibrous tissue. In the above case there had been dehis- 
cence of at least one Graafian follicle, for a cicatrix was found. An 
accessory ovary may become cystic. Mr. Doran has pointed out that 
small fibromyomas may arise in the ovarian ligament, and be mistaken 
for accessory ovaries ; but in most of the recorded cases there seems to 
have been little doubt of the glandular character of the bodies. 

Accessory ovaries are probably constricted portions of the normal 
organ which have been separated at an early period in the development, 
possibly by the agency of foetal peritonitis ; in rare cases the ovary has 
even been found divided into two nearly equal parts by such a constric- 
tion. At the same time traces of peritonitis are not always present, 
and then it is possible that the accessory glands were produced by a 
form of budding of the primitive sexual gland. This latter hypothesis 
is strengthened by the fact that in some instances the accessory ovary 
consisted entirely of Pfliiger's tubes. It is also possible that cases of 
this kind may have given rise to the notion that both ovary and testicle 
were present in the same individual, the accessory ovary with its tubu- 
liferous structure being regarded as a testicle. 

3. Hypertrophy of the Ovary. — Occasionally ovaries of twice the nor- 
mal size have been found in the infant at birth. This may be due to 
hyperplasia of all the component parts of the gland ; or to an increase 
in the connective tissue elements with destruction of the Graafian fol- 
licles, the result possibly of foetal oophoritis. In twin-bearing women 
the ovaries, according to Hellin, contain an unusually large number of 
ovisacs, a persistence, in fact, of the foetal character of the glands. 

4. Absence of the Ovaries. — Complete absence of both ovaries, save 
in sympodial and aeephalic foetuses, is an exceedingly rare anomaly. It 



MALFORMATIONS OF THE GENITAL ORGANS hV IV OMAN 67 

can only be absolutely proven by a post-mortem examination of both 
pelvis and abdomen ; for the glands may exist in a rudimentary state, 
or in an unusual position, and so escape notice clinically. 

Absence of one ovary is also a rare defect, but its occurrence is well 
established. It is usually, but not invariably associated with absence of 
the corresponding half of the uterus (u. unicornis), and of the tube of 
the same side ; one kidney is also wanting in certain cases. It would 
seem, therefore, that defect of the sexual gland is apt to carry with it 
absence of the Mtillerian and segmental ducts and Wolffian body. 

5. Rudimentary State of the Ovaries. — This is much less rare than 
complete absence of one or both ovaries. The glands are small in size 
and have either the foetal or the adult form. Microscopically they may 
show no Graafian vesicles ; they may consist simply of connective tis- 
sue, with vessels and scanty muscular fibres, or they may exhibit a few 
ill-developed ovisacs in the midst of ovarian stroma. Sometimes, by 
the persistence of Pfltiger's tubes in an unclosed state, they may simu- 
late testicles. They may occupy their normal position ; or, as in Blot's 
case, they may lie near the upper angle of the uterus ; or, again, they 
may be found herniated in the inguinal canal. They may coexist with 
accessory ovaries, with rudimentary Fallopian tubes, with a bifid or 
foetal uterus, and with stenosis of the aorta. At the same time the 
uterus may be normal, and the ovaries rudimentary and conversely. 
Such defects in ovarian development may be due to foetal oophoritis 
or peritonitis, or to torsion of the pedicle of the gland. 

6. Displacement of the Ovaries. — Non-descent of an ovary is a rare 
but not unknown anomaly. IMr. Bland Sutton has reported a case in 
which the right ovary was adherent to the lower border of the kidney 
of the same side, and I have seen a case in the new-born infant in 
which it was attached by peritonitic bands to the csecum. It has been 
stated that it may be found free in the peritoneal cavity, or adherent 
to the omentum ; it may then be cystic. 

Instead of non-descent, there may be dislocation of the ovary down- 
wards into the inguinal canal. According to Puech, congenital inguinal 
hernia of the ovary is much more common than acquired, and Zinnis 
has recently reported an instance of it; but Bland Sutton states that 
he knows of no case in which the ovarian nature of the herniated body 
has been proved by microscopical examination conducted by a compe- 
tent observer. Herniation of the ovary, which may be unilateral or 
bilateral, is usually associated with displacement of the Fallopian tube, 
and sometimes with malformation of the uterus and malposition of the 
kidney. It may be due to defective development of the round ligament 
and a patent condition of the canal of Nuck. A congenital crural, ova- 
rian hernia has not yet been observed. 

Clinical Features. — The presence of supernumerary or accessory ovaries 
is no guarantee of fertility ; for in certain of the recorded cases the pa- 
tients, although married, had not borne children. The woman seen by 
Olshausen, however, had had three confinements. Sterility in these 



68 SYSTEM OF GYNECOLOGY 

cases is to be accounted for by the cystic or atrophic state in which 
the ovaries, both normal and accessory, are often found ; and possibly 
the foetal peritonitis, which caused the division of the gland, led also 
to destruction of the ovisacs in it. In another direction, however, ac- 
cessory ovaries have a certain clinical importance ; their presence may 
explain the occasional persistence of menstruation after double ovari- 
otomy or oophorectomy, as has been pointed out by Homans and others ; 
the removal of three entirely separate ovarian cystomata or dermoids 
is rendered possible, as in Sippel's case ; and the occurrence of preg- 
nancy after a double ovariotomy finds a very probable explanation. 
Their diagnosis must always be a matter of great difficulty ; but their 
occasional presence must be borne in mind when small bodies are felt 
in the pelvis near to, or even at some distance from the normal ovaries. 

The clinical importance of absence or of a rudimentary state of the 
ovaries depends greatly on the unilateral or bilateral character of the 
anomaly. If only one ovary be absent there may be no interference 
with the patient's reproductive power ; for in the case reported by 
Busch, and quoted by Lawson Tait, the woman, notwithstanding uni- 
lateral absence of tube and ovary, had borne ten children. When, on 
the other hand, both ovaries are wanting or imperfect, indications of 
the defect are usually forthcoming at the time of puberty. Then there 
is an absence of the changes peculiar to this age, such as the establish- 
ment of the menstrual flow, the growth of hair on the mons veneris, 
and a rounding of the figure ; the individual approximates rather to 
the male than to the female type, or possibly retains the characters of 
infancy, with or without idiocy or cretinism. Exceptions occur, how- 
ever, in which the woman shows the normal female character and has 
active sexual desire. Epilepsy may occasionally appear at the period 
of puberty; Skene believes that defective development of the ovaries 
is of importance as a cause of mental weakness, and even of insanity, 
for normally the brain is stimulated to higher development by the 
.demands of these organs. There would seem also to be more than an 
; accidental connection between chlorosis and imperfectly formed ovaries. 
In adult life sterility is the constant result of a bilateral absence of the 
;-sexual glands ; and it may be accompanied by the growth of hair on 
the face, and especially on the upper lip. 

It is extremely difficult, if not impossible, to determine during life 
the existence of the ovarian defects under consideration : vaginal, rectal, 
and vesical touch, even when combined with abdominal palpation, often 
fail to establish a sure diagnosis ; and nothing short of laparotomy gives 
certainty. Yet it is very important that the anomaly should be detected, 
or at least suspected, if only to save the patient and her medical at- 
tendant from the dissatisfaction and disappointment consequent upon 
■the employment of a long and futile course of treatment for the es- 
tablishment of menstruation by means of stem pessaries and the like. 
Even when fairly conclusive evidence of the rudimentary state of the 
ovaries exists it is by no means certain that the lesion is truly congenital, 



MALFORMAIIOXS OF THE GENITAL ORGANS IN WOMAN 69 

for scarlet fever and other zymotic affections occurring in childliood 
may lead to their injury. 

Ovarian hernia is suggested by the presence of a rounded or oval 
body in the inguinal canal or lalDium majus, whether on one or both 
sides, when it occurs in an individual with a uterus and external genitals 
of the female type. For a certain diagnosis of the displaced gland 
microscopical examination is necessary, but the absence of the ovary 
from its normal position in the pelvis as determined by bimanual ex- 
amination, the enlargement of the herniated body at the menstrual 
periods, and the existence of dysmenorrhoea and dyspareunia, usually 
justify the provisional diagnosis of inguinal ovarian displacement. It 
must be borne in mind that the dislocated gland may undergo cystic 
changes which Avill mask its true nature. AVith regard to treatment, 
attempts at reduction almost invariably fail ; and palliative measures, 
such as wearing a hollow pad over the ovary, are rather indicated. 
When the gland becomes inflamed or cystic, ovariotomy will be neces- 
sary ; but when it is healthy it ought not to be removed, for pregnancy 
has been known to occur even with double ovarian hernia. 

Malformatioxs of the Fallopiax Tubes. — Since it has become 
customary to perform abdominal section for the relief of various 
morbid states of the viscera, attention has been more specially directed 
to the study of the malformations of the Fallopian tubes; and it 
is now known that these ducts may exhibit many anomalies with some 
of which earlier writers were unacquainted. The exact bearing of these 
abnormalities upon the physiology and pathology of reproduction is not 
fully determined ; but there is reason to believe that ectopic pregnancy 
may, in some instances at least, be due to developmental errors in the 
tubes. Tubal anomalies, like those of ovaries, may be roughly classified into 
those of excessive formation, those of defect, and those of altered rela- 
tion. These terms, however, must not be taken in a strictly literal sense. 

Pathology. — 1. Supernumerary Fallopian Tubes. — Examples of com- 
plete duplication of the tube, like genuine cases of supernumerary ovary, 
are extremely rare ; the two conditions may be associated. Instances 
have been reported by Keppler, Falk, and Ruppolt ; the last named 
author was of opinion that in his case the tube and ovary had been 
divided into two parts by the action of fatal peritonitis. 

2. Accessory Tubal Ostia and Tubes. — Another tubal malformation, 
which may be reckoned among those '* by excess," is the presence of 
accessory ostia or tubes. Opinions vary as to their frequency ; Eichard 
found them as often as five times in thirty cases ; Kossmann noted them in 
from 4 to 10 per cent ; and J. D. Williams and the present writer observed 
two examples in sixty-one consecutive autopsies (Fig. 31). From 3 to 6 
per cent is doubtless the usual proportion. Until recently more than 
three accessory ostia on one tube had not been observed, and commonly 
there are one or two only ; but Ferraresi has put on record a remarkable 
case in which there were six. The ostia are either sessile or have 



70 



SYSTEM OF GYNAECOLOGY 



pedicles consisting of accessory tubes ; they are usually surrounded 
by fimbriae. They are generally situated near the normal abdominal 
opening, and on the upper convex border of the tube ; but sometimes 
they lie midway between the normal ostium and the uterine end of the 
oviduct. Usually they communicate with the tubal lumen. Doran 
explains the origin of accessory ostia by partial failure in the closure of 
the groove in the germinal epithelium which forms the upper part of the 
Mlillerian duct; at the same time he thinks that they may also be due 
to splitting along the outer edge of Mtiller's duct after it has formed a 
closed tube. Kossmann, however, believes that they are occasioned by 



A 



B 



D 






ft 






j^ 



-J 



\ 



'" H -J 

Fig. 31. — Anterior view of right uterine appendages, showing accessory abdominal ostium of tube. 
A, Uterus ; B, cut surface of mesovarium ; C, right Fallopian tube ; D, fimbriated extremity ; E, 
accessory ostium abdominale ; F, free fold of anterior layer of mesosalpinx ; G, pedunculated cyst; 
H, right ovary. 

the existence of a supernumerary embryonic '^ anlage " (rudiment), lying 
parallel to the primary one. 

3. Tubal Appendages or Accessory Fimbrm. — Ferraresi gives the 
name tubal appendages (" appendici tube ") to certain structures, not un- 
commonly met with, which may be identified with the " pedunculated 
tufts of fimbriee " described by Bland Sutton. Superficially they bear a 
resemblance to accessory ostia, but their stalk is solid, and they show no 
ostium. Eerraresi found them six times in forty cases, and when present 
they occupy the same positions as accessory ostia ; two have been seen 
on the same tube. Bland Sutton regards them as ruptured cysts of 
Kobelt's tubes ; but more probably they have the same origin as the 
accessory fimbriated ostia. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 71 

4. Anomalies in the Length of the Tubes. — In cases of ovarian hernia 
the tube has often an unusual length. Even when there is no such 
displacement it may attain abnormal dimensions — 16 to 17 cms. in 
length according to Sinety. The normal length is from 10 to 11 cms., 
and the longest tube met with by J. D. Williams and myself meas- 
ured 14 cms. 

The tubes may also be of unequal length — sometimes the right, 
and at other times the left being the longer. Winckel says with regard 
to primary or congenital inequalities, that the embryonal causes may be 
an unequal length of the " anlage," irregular position, restricted motion 
from the pressure of neighbouring organs, or increased traction from 
foetal peritonitis. 

5. Absence of the Fallopian Tube. — Absence of the tubes may be 




Fig. 32. —Congenital absence of outer two-thirds of right Fallopian tube. (Post, view.) A, Fundus 
uteri; B, B, tubercular nodules in isthmus of each Fallopian tube; C, parovarian cyst; D, D, 
ovaries ; E, cone-like end of right Fallopian tube, outer two-thirds being absent ; F, cut margin of 
right mesosalpinx ; H, fibroma of right ovary ; k, adhesions on posterior wall of uterus. 



bilateral ; but more frequently one only is wanting. In the former case 
the defect is usually associated with absence of the uterus ; whilst in the 
latter the uterus unicornis is commonly present, the absent uterine horn 
being on the same side as the absent tube. Colomiatti, however, has 
reported a case in which the vagina and uterus were well formed, and yet 
the right tube and ovary were absent. Unilateral defect of the tube 
usually carries with it absence of the ovary ; but this is not invariable, 
for in Blot's specimen the gland was present but rudimentary. In cer- 
tain instances the corresponding kidney is also wanting. The want of 
development of the upper part of Mliller's dnct is doubtless the cause of the 
anomaly ; when the whole duct is absent there is also a unicornate uterus. 
6. Rudimentary State of the Tubes. — In rare cases the outer part of 
the tube is absent ; thus, in a case of genital tuberculosis, J. D. Williams 
and the writer noted congenital absence of the outer two-thirds of the 
right oviduct, the inner third having a lumen and tapering to a point at 
its outer end (Fig. 32). In a post-mortem room specimen Sir T. Grainger 
Stewart observed that the tubes were shorter than normal, ended blindly, 
and were connected by bands with the peritoneum covering the rectum. 
Absence of the outer part of the tube does not necessarily carry with it 
defect of the corresponding ovary ; but in the case seen by Marchand it 



72 SYSTEM OF GYNECOLOGY 

did so. Doubtless the anomaly is due to foetal peritonitis. Sometimes 
only the fimbriae of the ostium abdominale are wanting. 

Partial or complete absence of the normal tunnelling of the tubes 
may be met with; and then these organs are represented by solid cords 
of fibrous or muscular tissue. Sometimes it is at the abdominal end only 
that the tube is imperforate : in the case described by Dr. Haultain the 
outer extremity of one tube was quite smooth, like the finger of a glove ; 
the tubal mucosa showed no folds, and the ovary on the same side was 
cirrhotic and cystic. Absence of the tubal lumen is simply the persistence 
of the normal condition of the embryo ; whilst an imperforate state of the 
ostium abdominale must be due to want of development of the Mtlllerian 
funnel which should open into the splanchnocele. 

During foetal life the tubes normally exhibit spiral convolutions both 
in the isthmus and ampulla; at birth these have disappeared in the 
isthmus, and in the adult they ought to be entirely absent. Sometimes, 
however, the convolutions persist, as in some of the specimens described 
by Popoffc" ; but Haultain is of opinion that tubal contortion in the adult 
is more commonly due to a return to the foetal state than to a persistence 
of it. If endosalpingitis occur in such a tube it is easy to understand 
how hydrosalpinx or pyosalpinx may be initiated. 

7. Displacement of the Tubes. — It is stated that the tubes may show 
an unusually low implantation into the uterus — a misplacement which 
has been regarded as one of the causes of placenta preevia. Displacement 
of the tubes in various directions may be the result of foetal peritonitis, 
as in a specimen shown by myself to the Edinburgh Obstetrical Society ; 
and in cases of ovarian hernia the tube usually accompanies the gland. 
A curious case of backward dislocation of the tubes, with union of 
their abdominal ostia to form a ring behind the uterus, was reported 
by Hllter; but some doubt existed as to the congenital nature of the 
anomaly. 

8. The Hydatid of Morgagni. — This name is often loosely applied to 
pedunculated cysts arising from the curved tubules of Kobelt (parova- 
rium), or to stalked terminal cysts of Gartner's duct ; but it ought to be 
reserved for the much less common cyst which is found attached by 
a pedicle to the tube or to its fimbriae. J. D. Williams and myself met 
with it in 8 per cent of the adult cases examined by us ; it varies in size 
from that of a pea to a small bean ; it is lined by a mucosa with simple 
folds covered by a single layer of ciliated columnar epithelial cells ; its 
wall is always composed of muscular fibres arranged circularly and 
longitudinally; its outer membrane is the peritoneum; its stalk is 
always muscular ; and its contents are clear, limpid fluid. Thus it may 
be distinguished from the false hydatids of Morgagni. It has been 
regarded as the remnant of the upper end of Mliller's duct. 

Clinical Features. — Malformations of the Pallopian tubes are sel- 
dom diagnosed during life. They may be discovered during the per- 
formance of laparotomy, or their existence may be suspected when 
anomalies of the uterus or ovaries are known to be present ; but the 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 73 

symptoms to which they give rise are not distinctive, and the physical 
signs associated with them are most difficult of recognition. 

Absence or imperforate condition of the tubes, if bilateral, will be the 
cause of sterility ; and if in such cases the ovaries be present, the rupture 
of Graafian follicles and the discharge of ova into the abdominal cavity 
may occur at menstrual epochs, with the consequent formation of small 
hsematoceles and the occurrence of localised peritonitic attacks. Unilat- 
eral absence or imperf oration is not a bar to conception, for the tube of the 
opposite side may transmit the ovum to the uterus. Spirality of the 
tubes or clisplaceinent may be causes of dysmeiiorrhoea and also of sterility. 
It has been thought that an accessory ostium may be a factor in the pro- 
duction of ectopic pregnancy — the ovum passing into the tube by the 
normal ostium, becoming impregnated, and passing out into the peritoneal 
cavity by the accessory orifice — but there is no proof that this can 
happen. On the other hand, Sanger has recently shown that an accessory 
ostium may serve for the ovum, as a means of access to the tube and 
uterus when the normal tubal openings are closed on both sides by in- 
flammatory processes. 

Malformatioxs of the Eouxd axd Broad Ligamexts. — Mal- 
formations of the round ligament are occasionally met with, but they have 
been little studied, and are doubtless commonly associated with abnormal 
states of the uterus, tubes, or ovaries. Persistence of the canal of 
ISTuck, in which the ligament lies, gives rise to hydrocele in the woman. 
The broad ligaments, like the round, may be absent, rudimentary, or 
unequally developed. The ligamenta lata also may be congenitally dis- 
placed ; and they often contain ^\ithin their folds cysts which have de- 
veloped in the mesonepliric relics which form the organ of Eosenmtiller 
or parovarium. 

MalfoPvMAtioxs of the Uterus. — Malformations of the uterus 
form a large and interesting group of genital anomalies, the mode of 
origin and clinical manifestations of which have long been the subject 
of extended investigations. The various types of uterine anomaly are, 
therefore, well known : their pathogenesis is, with one or two exceptions, 
agreed upon, and their influence on the general and sexual health of the 
individual is, to a large extent, understood. Saint-Hilaire, Kussmaul, 
Ptlrst, Lefort, and Klebs have all by their researches greatly increased 
our knowledge of uterine malformations. 

Various plans of classification have been proposed, of which that 
by Liviiis Fiirst is the most complete and philosophical. He divided all 
anomalies of the uterus into three groups, according to the period of intra- 
uterine life in which they were produced — those originating between 
the first and eighth weeks, those between the eighth and twentieth, and 
those between the twentieth and fortieth weeks. In the first group were 
partial or total absence of the uterus, and a solid or partly excavated 
condition of the organ, which might be single, double, or bicornate. In 
the second group were certain minor malformations characterised by 



74 SYSTEM OF GYNECOLOGY 

trifling alterations in external form, and by the presence of a more or 
less marked septum internally. The third group contained a single 
variety, the uterus which retained its foetal characters so far as the 
presence of rugae and the disproportionate size of cervix as compared 
with the body of the organ were concerned. This scheme, although 
invaluable to the teratologist, deals too much with minor details for the 
practical purpose of the gynaecologist. It will be convenient simply to 
divide uterine anomalies, like those of the tubes and ovaries, into three 
groups : those in which there is apparent excessive formation, those in 
which defect is the leading character, and those which show altered rela- 
tionship of parts. The word apparent is inserted, because that which 
is commonly called a " double " uterus is really an organ the two compo- 
nent parts of which, derived from the two Mtillerian ducts, have not fused 
into one. It will be well to study together the pathology and symp- 
tomatology of each variety, for several of them are of considerable 
interest and importance from the gynaecological standpoint. 

Uterus Accessorius and Trifid Uterus. — Pathology. ■ — The uterus 
accessorius and the trifid uterus are probably the rarest anomalies of that 
organ which have been recorded. In 1894 Hollander, during the per- 
formance of laparotomy, found a second uterus lying in front of the 
normal one, between it and the bladder. This he termed a " uterus 
accessorius." The normal organ was supplied with normal tubes and 
ovaries, had the round ligaments attached to it, and was retroflexed. 
The accessory uterus had neither annexa nor round ligaments, was 
anteverted, and contained some placental tissue. There was a single 
cervix with two orifices separated by a bridge of tissue. Each orifice 
communicated with the interior of one uterus. In a similar case, observed 
clinically by Skene, there was a small second uterus lying in front of the 
normal one. 

Depage, also during a laparotomy, found a still more complicated and 
puzzling uterine anomaly, which he termed " trifid uterus." There was 
a bifid uterus with a single cervix and two internal cervical orifices ; but 
there was also found, attached to the cervix, a third uterine lobe forming a 
closed sac containing altered blood. Blood cysts were found in the ovaries. 

It is difficult to offer a satisfactory explanation of the mode of origin 
of these two malformations. It might be thought that in the case of the 
uterus accessorius we had to do with a uterus didelphys in which rotation 
had brought the two horns into an antero-posterior relation ; but this 
supposition utterly fails to explain the attachment of the annexa and 
round ligaments to one uterus. The most feasible explanation of both 
the accessory and the trifid uterus is that during embryonic life a diver- 
ticulum is formed from one of the Mtillerian ducts, and that this develops 
into the supplementary organ. If this be so, these anomalies fully deserve 
to be called malformations "by excess," which the so-called "double" 
uterus does not. 

Clinical Features. — Hollander's patient had had seven labours, and 
had thrice aborted, once with twins, at the fourth month. The placental 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 75 

tissue was found in the uterus accessorius, that is, in the organ without 
annexa. Skene's patient suffered from leucorrhoea from the accessory 
uterus. The case seen by Depage was in a young unmarried girl ; and in 
this instance, as well as in that of Hollander, an entirely erroneous 
diagnosis was made, and the true state of affairs was discovered during 
laparotomy. 

Uterus Didelphys. — Pathology. — The uterus didelphys — or, as it has 




Fig. 33. — Uterus didelphys. (After Eisenmann and Martin.) a, a, Double vaginal entrance ; 5, 
urethral opening ; c, urethra ; d, d, double vagina ; e, e, double cervical orifice ; /, /, double cervix ; 
g, g, double uterine body ; h, h, round ligaments ; i, ^, Fallopian tubes ; k, k, ovaries. 

also been named, " diductus," " duplex," or '• separatus " — exhibits the 
maximum degree of separation of the two laterally placed halves which 
normally fuse into the single uterus (Fig. 33). There appear to be two 
single uteri lying side by side, each, however, possessing only one ovary, 
tube, and round ligament. There may, also, be complete or incomplete 
duplication of the vagina (septa or subsepta) ; or that canal may be single 
{simplex). The two wombs are seldom exactly equal in size, and one of 
them may be imperforate, a condition giving rise to hsematometra at 



76 SYSTEM OF GYNECOLOGY 

puberty. Not uncommonly this uterine malformation is associated with, 
deformities of neighbouring parts, such as ectopia vesicse and atresia ani. 
Among the causes which have been invoked to explain the want of 
union of the two Miillerian ducts, and the consequent formation of the 
uterus didelphys, are distension of the allantois, the absence of closure 
of the anterior abdominal wall, and the existence of adhesions between 
the rectum and bladder. 

Clinical Features. — Since it is impossible clinically to separate cases 
of uterus didelphys from those of uterus bicornis, it will be convenient 
to consider the symptomatology of the two malformations together. 

Uterus Bicornis. — Pathology. — A much commoner malformation is the 
uterus bicornis, in which the two halves or horns are not entirely separate, 
as in the didelphous organ, but are united more or less intimately at their 




Fig. 84. — Uterus bicornis. (After Schroder and Martin.) a, «, The vaginae, laid open; &, the left 
cervix ; c, the cervix, externally apparently single, but divided into two internally ; d, d, the two 
uterine horns ; e, e, the round ligaments ; /, /, the Fallopian tubes ; g, g, the ovai-ies. 

lower end ; that is, in the region of the cervix or lower part of the corpus 
uteri (Fig. 34). The middle portions of Mtiller's ducts have evidently begun 
to fuse together, but coalescence has stopped short of the normal, and 
an organ is produced exhibiting externally clear indications of its two- 
horned origin. The bicornate uterus is the connecting link between the 
uterus dideljjhys, in which the external appearances show two quite ununited 
halves, and the uterus sejJtus or bilocularis, in which outwardly the organ 
gives no indication of duplicity. The uterus bicornis also shows all the 
possible grades betAveen the variety in which there are two horns united 
only in the cervical region, and that in which the double character of the 
organ is indicated merely by a depression or notch at the fundus (uterus 
introrsum arcuatus or uterus cordiformis). The two horns may be prac- 
tically equal in size; but, on the other hand, one may be much less 
developed than the other, and in this way there is an approximation to 
the type of the uterus unicornis. All the intermediate varieties have 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 77 



been observed. The degree of separation of tbe liorns varies greatly. 
In the most marked cases they are far apart superiorly, and between 
them is frequently found a band or frenum (recto-vesical ligament) 
passing from the bladder to the rectum. In less evident cases the 
horns lie close together, but are not united ; and in yet other instances 
a shallow depression at the fundus shows that fusion of the two 
Milllerian ducts has closely approached the degree found in the normal 
uterus. When the horns are markedly separate the left one is usually 
directed slightly forwards, showing that some degree of uterine torsion 
has occurred. In other cases they may lie exactly side by side. 

The cervix uteri may be broad and large, and may show a double orifice 
(uterus bicornis duplex, septus, or bicameratus) ; it may be large, but with 
only one os ; or it may be of normal size and provided with a single 
orifice (uterus bicornis unicolUs). The vagina may be septate, subseptate, 
or single, and the external genitals are usually normal. Sometimes 
there are anomalies of neighbouring or more distant organs, for example 
ectopia vesicce ?iYidi Polydactyly ; and such monstrosities as cyclopia and 
anencephcdy have been noted in non-viable infants with this type of 
uterine anomaly. 

With regard to the internal appearances of the uterus bicornis it is 
common to find a septum dividing that part of the organ which appears 
single externally into two compartments internally. In other cases one 
or both horns may be solid, semi-solid, or imperforate at one or more 
places. In such instances an accumulation of blood may occur at puberty 
behind the imperf oration. The cervix may show a double or a single canal. 

Clinical Fecdures. — Apart from the reproductive functions the uterus 
bicornis has little clinical importance ; but it has recently been noted that 
chlorotic girls are not infrequently the subjects of this type of anomaly, 
and probably chlorosis is to be regarded as a developmental morbid state. 
It has been affirmed also that in early life difficulty may arise in the 
evacuation of the bladder and bowel from the concomitant malformations. 

The menstrual functions may be variously affected by the presence of 
a didelphous or bicornate uterus. Menstruation may occur ever}^ fort- 
night, every month, or once in two months. In the first case the discharge 
comes from both uterine cavities each month, but there is no coincidence 
of dates, and therefore it has a fourteen day interval. In the second case 
there is either a simultaneous discharge from both wombs, or else the 
menstrual flow is from one cavity the one month and from the other the 
next. And in the third instance, as is shown by a case reported by T. A. 
Emmet, there is a bimonthly flow from one half, whilst on the other side 
there is an imperforate condition of the horn, vagina, or hymen, which 
prevents the appearance of a discharge. Dysmenorrhoea is often met 
with and amenorrhoea occasionally. 

Sterility is sometimes associated with the bicornate uterus, but, on 
the other hand, the patient is often fertile. Pregnancy may occur in one 
horn, and a menstrual discharge take place from the other; a circumstance 
which possibly accounts for the continuance of menstruation during 



78 



SYSTEM OF GYNECOLOGY 



gestation which has been occasionally noted. Decidual membranes may 
also form in the empty horn. Pregnancy may also occur in both horns 
simultaneously, or at different but not far distant dates ; and in the latter 
case may be found the explanation of some of the anomalous instances 
of superfoetation. There is evidence to show that gestation may happen 
in each horn alternately. In rare cases a twin conception has taken place 
in one horn. 

The bicornate uterus may abort ; or labour may occur at the full 
term, when the empty horn may show contractions as well as the gravid 
one, and its os also may open. Parturition may be normal ; there may 
be a malpresentation ; the recto-vesical band may cause delay in the 
passage of the foetal head, or there may be low implantation of the 
placenta and haemorrhage. When, as sometimes happens, the pregnant 
horn is shut off by a septum, gestation becomes practically extra-uterine, 
and has all the dangers associated therewith, such as uterine rupture. 
Even in cases in which there is not unilateral atresia, rupture of the 
uterus, or of the septum between its horns, may occur. 

The diagnosis of the presence of a bicornate uterus is often not 
made till pregnancy and labour have taken place ; and sometimes not 
even then. When menstruation occurs every fortnight, or persists 
during pregnancy, the anomaly may be suspected. The presence of a 
double vagina, cervix, or os uteri suggests the existence of a double 
uterine cavity ; and a thorough bimanual examination, conjoined with 
the careful use of the sound, if there be no evidence of pregnancy, 
ought to clear up the case. The instances in which one horn is 
imperforate are rarely diagnosed. 

Uterus Septus. — Patliology. — The uterus septus, or, as it is also called, 
bilocularis or globularis, by its external appearance gives no indication of 

the fact that internally it is 



^iZ 




divided, more or less com- 
pletely, into two cavities by 
an antero-posterior vertical 
septum or partition (Fig. 35). 
The cases in which the septum 
is imperfect have, however, 
also been grouped together 
under the name ^iterus sub- 
septus, or semipartitus ; and, 
according to the extent of the 
partition, certain subvarieties 
have been distinguished. 
Thus, when it is found in 
both body and cervix, leaving, 
however, the os externum 
uteri single, we have the ute- 
rus siibseptus uniforis. When 
it exists in the body, but does not extend beyond the os internum, there 



Fig. 85. — Uterus septus. (After Gravel and Martin.) a, 
Vagina ; b, single, lower part of cervix ; c, c, septum, 
thicker above, thinner below ; d, d, right and left 
uterine cavities ; e, e, two projections near the os 
internum uteri ; /, fundus uteri ; g, g, Fallopian tubes ; 
h, h, round ligaments. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 



79 



is produced the uterus subseptus unicollis. When it is present only in 
part of the body it constitutes the uterus subseptus unicorporeus ; and 
when it is found only near the os externum it is the uterus biforis supra 
simplex. From this enumeration of its varieties the pathological charac- 
ters of the uterus septus will be evident. It may be added that the 
best-marked type has a normal fundus, two uterine cavities situated 
laterally, and existing both in body and cervix, and not infrequenth" 
there is also a partially or completely sej^tate vagina. The uterus septus 
shows, therefore, a more advanced degree of fusion of the Mtillerian ducts 
than does the uterus bicornis ; but still the fusion is incomplete, as is 
shown by the more or less perfect septum which remains. 

Clinical Features. — What has been written regarding the clinical 
manifestations associated with the uterus bicornis may be applied also 
to the uterus septus. Further, an incomplete septum may be the cause 
of a malpresentation — for instance, a transverse case — or of a low in- 
sertion of the placenta. The after-birth may even be attached to the 
septum itself — an arrangement certain to give rise to dangerous hsemor- 
rhage after the birth of the infant. It would seem that abortion is coin- 
mon in this uterine anomaly ; at any rate Ruge, by dividing the septum in 
the case of a patient who had twice miscarried, Avas rewarded by finding 
that her next pregnancy went to the full term. The diagnosis of the 
uterus septus is only likely to be made during labour, when the hand, 
introduced into the uterus to perform version or to extract the placenta, 
may detect the presence of the partition. As with the uterus bicornis 
one cavity may not communicate with the vagina, and thus hsemato- 
metra with its train of symptoms may arise. 

Uterus Unicornis. — Pathology. — The uterus unicornis is an organ in 
which one horn alone is well developed (Fig. 36). There are two varieties : 
that in which the second horn is altogether absent (uterus u7iicorv is sine ullo 
rudimento cornu alterius), and that in which there is a solid or hollow 



rudiment of it (uterus unicornis 
cum rudimento cornu alterius 
solido seu excavato). In the 
former case there is complete, in 
the latter partial defect of one of 
the Mtillerian ducts. The uterus 
unicornis has really no fundus, 
the single horn inclining to one 
side of the middle line and 
tapering to a point at which it 
is continuous with the Fallopian 
tube, and where the round liga- 
ment is attached. The ovary 
thus comes to lie at the apex 
of the bent cone formed by the single horn and the corresponding tube. 
The cervix uteri is usually small and the vagina narrow, absent, or septate. 
The single horn may also be imperfectly developed, and may be solid or 




. — Uterus unicornis, posterior view, (A fter Pole 
and Martin.) a, Eight half of uterus ; the left horn 
has not been developed ; &, right Fallopian tube ; c, 
left Fallopian tube ; d, left ovary ; e, bladder ; /, 
vagina ; g, right ovarian ligament. 



8o SYSTEM OF GYNECOLOGY 

partly excavated. Certain concomitant malformations have been noted : 
thus, the Fallopian tube, round ligament, and broad ligament are 
commonly absent on the side of the missing horn ; the corresponding 
ureter and kidney may also be wanting, and the bladder may be developed 
only on one side. The ovaries may be present, but are often rudimentary. 

In some cases, as has been stated above, a rudiment of the second 
horn may be present ; it may be solid or hollow, and in the latter case 
its cavity may or may not communicate with that in the first horn. 
Such cases form the connecting links between the typical uterus unicor- 
nis and the bicornate organ. This rudimentary horn may be the seat 
of a pregnancy, or a collection of menstrual blood may be found in 
it. A fibroid tumour may be found attached either to it or to the other 
better-formed horn, as in a case noted by Mangiagalli. 

Clinical Features. — A patient with a uterus unicornis commonly 
gives a history of amenorrhoea; but sometimes menstruation goes on 
normally, and pregnancy occurs in the single horn. When a rudimentary 
horn is present, and when it becomes the seat of a gestation, a very serious 
state of affairs is established ; in fact the case becomes practically one of 
extra-uterine pregnancy, and is accompanied by the same dangers, that 
is, rupture and intra-abdominal hsemorrhage. When the rudimentary 
pregnant horn has no communication with the uterus unicornis it seems 
necessary to admit extra-uterine migration either of the ovum or of the 
semen. 

The presence of a uterus unicornis, with or without a rudimentary 
horn, commonly passes unnoticed during life ; unless it be discovered 
during the performance of laparotomy. If the condition be suspected, a 
careful bimanual examination, aided by the use of the sound, will reveal 
the presence of a thin, elongated uterine body bent to one side with its 
concavity outwards. There will also be a small cervix and a narrow 
vagina. Pregnancy in the rudimentary horn cannot be distinguished 
from an ectopic gestation of the tubal variety, unless rupture occur and 
the abdomen be opened. In a case seen by myself it was mistaken for 
a fibroid tumour, a mistake which laparotomy revealed. 

Uterus Rudimentarius. — Pathology. — The name uterus rudimentarius 
is a vague one. From one point of view it may with propriety be 
applied to such anomalies as the uterus unicornis or bicornis. Further, 
the distinction between it and complete absence of the organ can only be 
made after a careful autopsy. At the same time, it has been customary 
to restrict the application of the term to the cases in which, in place of 
the normal organ, one finds a body of variable form consisting of fibrous, 
muscular, or fibro-rauscular tissue, sometimes solid and at other times 
showing a rudimentary cavity (uterus rudimentarius solidus, uterus rudi- 
mentarius partini excavatus). Through its partly excavated variety it is 
closely related to atresia of the single uterus. In one form of the 
rudimentary uterus the walls are so thin that it has been called 7nem- 
hraniform or the uterus menihranaceus. More commonly, however, a small 
solid mass of muscular tissue is found in the middle line between the 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 8i 

folds of the broad ligament, which, seems in such a case to sweep in an 
almost unbroken band from one side of the pelvis to the other. The 
tubes, ovaries, cervix, and vagina are usually absent or very imperfect ; 
but cases have been reported in which the annexa were normal. The 
external genitals are, as a rule, well formed. The mammae are usually 
small, and there is often a poor growth of hair on the mons veneris. 

Clinical Features. — Since clinically the rudimentary uterus cannot 
be distinguished from absence of the organ, the symptomatology of 
the two conditions will be considered together. The recent literature 
of both anomalies will be given at the same time. 

Uterus Deficiens seu Defectus Uteri. — Pathology. — Complete absence 
of the uterus, its annexa, and (to some extent also) the external genitals, 
is met with commonly enough in the acardiac twin and in sympodial 
foetuses ; but its occurrence in the adult and otherwise normal individ- 
ual is very rare. It is necessary to make a complete post-mortem ex- 
amination before it can be definitely said that no uterus existed ; and 
in most of the reported cases such evidence is not forthcoming. Eur- 
tlier, in certain instances the individual was evidently a male with un- 
descended testicles, not a female without a uterus. 

When the Fallopian tubes as well as the uterus are absent the 
peritoneum passes directly from the bladder to the rectum ; but when 
they are present it forms a mesentery for each, although even then 
broad ligaments in the strict sense of the term can scarcely be said to 
exist. The round ligaments are generally to be found ; they end in the 
cellular tissue between the rectum and bladder. The ovaries may be 
absent, but generally they are present, and then they commonly contain 
no ovisacs ; very rarely they are normal. The tubes when present are 
simply solid rods of tissue, with usually an open ostium abdominale. 
The vagina is often wanting entirely ; but sometimes there is a shal- 
low cul-de-sac (vestibular canal) communicating with a vulva which is 
usually normal. There may, however, be an absence of the vulvar hair. 
In rare cases the vagina has been found well developed. The pelvis 
has a feminine breadth ; but the mammae are often poorly developed. 

Clinical Features. — A woman without a uterus, or with merely a 
rudimentary one, may have all the secondary characters of her sex ; she 
may have a high-pitched voice, rounded outlines, and an absence of hair 
on the face. Sexual desire may or may not be present — a circumstance 
which is probably determined by the state of the ovaries. Amenorrhoea 
is practically constant; as, however, ovulation may occur, menstrual 
molimina may be met with, and there may be vicarious haemorrhages or 
such acute pelvic pain as to necessitate an operation for the removal of 
the ovaries. There is; of course, sterility always ; but the patient may 
be capable of coitus to a certain extent. Usually, however, cohabitar 
tion is attended by great pain. Repeated attempts on the part of 
the husband deepen the shallow vestibular canal, converting it into a 
cul-de-sac of some depth; in other cases dilatation of the urethra is 
brought about. 



82 SYSTEM OF GYNAECOLOGY 

Although, it is impossible clinically to distinguish between absence 
and a rudimentary state of the uterus^ it is always possible to ascertain 
the existence of one or other of these anomalies. By passing the index 
linger into the rectum and a sound into the bladder, whilst the abdomi- 
nal wall is deeply depressed from above, one can determine that there 
is nothing like a fully formed uterus between the rectum and the blad- 
der. A transverse band consisting of the tubes may be palpated, as 
may also the ovaries when they are present. These physical characters 
taken in conjunction with the symptoms enable the gynaecologist to 
make a diagnosis sufficiently exact to prevent his continuing a hopeless 
course of treatment by ferruginous tonics and the like for the establish- 
ment of menstruation. 

Uterus Fcetalis. — Pathology. — The anatomical characters, which are 
normal in the uterus during intra-uterine life, may persist and be found 
in the adult. They then constitute an anomaly — uterus f oetalis. The 
cervix uteri is longer than the body, and its walls are thick, whilst those 
of the body are thin. The cervix also is conical and os externum nar- 
row. The whole organ is cylindrical in form, and is small in size, the 
sound passing in for a distance of only an inch or an inch and a half. 
The term infantile uterus may be used as a synonym for foetal uterus ; 
but a shade of difference has been recognised by some writers. In the 
uterus foetalis the folds of the mucous membrane are found in the body 
of the organ, whilst in the infantile organ they exist only in the cer- 
vix. The mucous membrane also is poorly developed, and, according 
to Sinety, contains no tubular glands. The vagina may be short and 
narrow, or it may be quite normal. The external genitals may be imper- 
fect, and the ovaries and tubes may either be normal or rudimentary. 
Mammary development is usually little marked. It may be added that 
the uterus foetalis may be also a uteris bicornis. 

Clinical Features. — With the uterus foetalis there is commonly 
amenorrhoea; sometimes, however, there is scanty and painful men- 
struation. Sterility is a constant symptom, and there may or may not 
be sexual appetite. Chlorosis has frequently been found associated 
with a foetal or infantile uterus. The heart may be small, and there 
may be a general hypoplasia of the whole vascular system. The uter- 
ine anomaly may be diagnosed by means of bimanual examination, 
aided by rectal touch and the use of the sound. The differential 
diagnosis between the uterus foetalis and the uterus pubescens is chiefly 
founded upon the state of the cervix. In the former it is fairly firm, 
especially in the supra-vaginal portion ; in the latter it is thin and re- 
laxed. The condition, however, may be complicated and to some ex- 
tent masked by concomitant perimetritis and metritis. Attempts at 
treatment of the anomaly have almost invariably ended in failure ; and 
practically the only thing to be done is to relieve the dysmenorrhoea, if 
it be present, by the use of drugs, or possibly, if severe, by oophorectomy. 

Uterus Pubescens. — Pathology. — The pubescent uterus occupies an 
intermediate position between the uterus foetalis and the normal virginal 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN %z 

organ. It shows a persistence of the anatomical characters which are 
normal before the epoch of puberty'. The organ is small in size, weighs 
less than normal, and has a cervix and a body of practically equal 
length. The ovaries, tubes, vagina, and mammae may or may not share 
in this condition of hypertrophy. 

Clinical Features. — The symptoms of pubescent uterus closely re- 
semble those associated with the foetal or infantile organ. Menstruation 
may be absent or scanty and irregular. Sterility is common, but there 
is always the hope that the organ may yet undergo further development 
and the patient become pregnant. Signs of general weakness, chlorosis, 
or rickets may coexist ; but the anomaly may also be met with in strong 
and healthy women. The diagnosis is made by the same means as in 
cases of foetal uterus, especial attention being paid to the condition of 
the cervix and its size compared with that of the body of the organ. If 
the condition be discovered before marriage, the treatment to be adopted 
is a general tonic one, consisting in the use of gymnastic exercises, of 
nourishing food, and of iron, quinine, and arsenic. After marriage the 
periodical passing of the sound, the insertion of an intra-uterine stem- 
pessary, and electricity may all be employed with some hope of success. 
The effect of marriage itself may be beneficial ; emmenagogues are of 
doubtful efficacy. Marriage ought not to be recommended unless men- 
struation has become established. 

Uterine Atresia and Stenosis. — Pathology. — The uterus may be con- 
genitally imperforate ; an anomaly which finds its explanation in the 
originally solid condition of the ducts of Miiller from which it is devel- 
oped. Uterine atresia is not so much an independent malformation as a 
complication of other anomalies of the organ, for instance of its bicornate 
and unicornate condition. Nevertheless it occurs also in cases of single 
and otherwise normal uteri. The whole cervix may be solid, or there 
may simply be a septum at the os externum or os internum uteri. At 
the age of puberty menstrual blood begins to accumulate behind the 
obstruction, leading in time to the distension of the uterus (hsematometra). 
When one horn of a bicornate uterus is imperforate, unilateral hsemato- 
metra is produced; when both horns are occluded there is bilateral 
hsematometra. When the obstruction is situated at the os internum, 
only the body of the uterus becomes distended, the cervical canal 
retaining its natural form. An accumulation of blood may be found in 
the tubes also (hsematosalpinx), and it woidd appear that the source of 
the blood is the tubal mucosa, and that it is not due to regurgitation 
from the uterine cavity. When there is simply narrowing of the cervical 
canal without atresia the condition known as uterine stenosis is produced. 

Clinical Features. — Since the symptoms of uterine atresia are mainly 
those of hgematometra, and since these are found also in association 
with atresia vaginae, their consideration will be deferred till that vaginal 
anomaly has been described. In the cases of uterine stenosis dysmenor- 
rhoea is the leading symptom, and dilatation of the cervical canal is 
needed for its cure. Uterine atresia requires puncture and subsequent 



84 SYSTEM OF GYNECOLOGY 

dilatation of the obstruction for its relief. This should be done with 
strict antiseptic precautions ; and when the accumulated fluid has es- 
caped the cavity should be packed with iodoform gauze for some days, 
and douched occasionally with weak antiseptic solutions. 

Transverse Septum in the Cervix Uteri. — Patliology. — A condition 
somewhat similar to atresia uteri is the presence of a valvular fold or 
diaphragm in the cervical canal. When the os externum has been di- 
lated the valve may present the appearance of a second cervix within 
the first. It is possibly produced in the same manner as the more 
common transverse septa of the vaginal canal. 

Clinical Features. — The septum would seem to act like a polypus, 
and give rise to haemorrhage and pain. It has been excised with com- 
plete relief of symptoms. It may also be the cause of dystocia ; but 
this is not a constant effect. 

Minor Malformations of the Uterus. — Miiller of Berne has 
recently pointed out the frequency of certain minor abnormalities of 
the uterine fundus. Amongst these is the anvil-shaped uterus (titerus 
incudiformis or hiangularis) , in which the normal convexity of the fun- 
dus is wanting, and a straight line joins the two Fallopian tubes. It 
closely resembles the uterus with a flat fundus (iderus planifandalis) of 
Flirst's classification, and may coexist with partial or complete duplica- 
tion of the uterus and vagina. 

The vaginal cervix may be rudimentary or absent (uterus parvicollis 
or acollis), whilst the body of the organ may be normal, small, atresic, 
or membraniform. A case of this kind has recently been reported by 
Penrose. Again, a frenum may be found dividing the os externum into 
two orifices (uterus biforis), a condition which is normal in the ant-eater 
(Pozzi). This exists without any other trace of duplication of the geni- 
tal canal. It may complicate labour, during which it may be torn and 
give rise to haemorrhage. In order to prevent this it ought to be kept 
to one side or divided between two ligatures. 

A condition which may easily be mistaken for the uterus unicornis 
is that in which there is asymmetry of the organ, one side being better 
developed than the other. The uterus bends towards the better-devel- 
oped side (latero-version or obliquity of the uterus), and the round liga- 
ment on that side is relatively short. Latero-position of the uterus is 
met with when one of the broad ligaments is less developed congeni- 
tally, and is to be distinguished from the acquired condition due to 
unilateral inflammation and cicatricial contraction. 

Congenital Prolapsus Uteri. — Patliology. — What has been called con- 
genital prolapsus uteri is an exceedingly rare anomaly. I have recently 
met with a well-marked example of it, in which there was a real displace- 
ment downwards of the whole uterus as well as a hypertrophic condition 
of the cervix. In my case, as well as in those of Heil, Quisling, Schaeffer, 
and Remy, there was also spina bifida in the lumbo-sacral region. Now 
these five instances are the only ones with which I am acquainted ; and 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 85 

the fact that in them all there was this association of spina bifida and 
prolapsus uteri, seems to point to a nervous factor in the etiology of 
the latter condition. 

Abnormal Communications of the Uterus. — The uterus may in rare 
cases communicate with the rectum or bladder, or with both viscera at 
once. In an extraordinary instance reported by Mr. Doran the right 
side of a bipartite uterus opened on the outer surface of the body. There 
may also be a communication between the uterine cavity and that of 
the ascending colon. Most of these anomalies must be ascribed to a 
partial or complete persistence of the embryonic cloacal condition. When 
combined with vaginal atresia it would seem that impregnation has 
occurred per rectum or per urethram. 

Malformatioxs of the Yagixa. — Vaginal malformations have 
many characters in common with uterine anomalies, a circumstance 
Avhich is easily understood when it is borne in mind that both vagina 
and uterus are derived from the Mlillerian ducts of the embryo. Fur- 
ther, vaginal and uterine abnormalities often coexist in the same case, 
and in many instances give rise to very similar symptoms. Whilst, 
however, it is rare to meet with abnormal communications between the 
uterus and neighbouring organs, such communications are much more 
frequent in the case of the vagina. 

Double Vagina (Vagina Septa). — Pathology. — A double vagina in 
the exact sense of the term can only be said to exist in certain double 
terata, such as the pygoj^agous twins ; but it has become customary to 
apply the name to the cases in which the two Mlillerian ducts, which 
normally fuse into one canal, have remained separate, a septum inter- 
vening loetween the two passages in part or in the whole of their extent. 

Just as the uterus didelphys is very rare, so two vaginal canals, com- 
pletely separated and each opening externally at a separate vulva, consti- 
tute an anomaly of a very uncommon form. The only reported case of 
the kind seems to have been that of Katharine Kaufmann, seen by Sup- 
pinger in 1876. This child, who died at the age of twenty-one months, 
had two vulvae each opening into a vaginal canal. The pelvis was broad, 
and the true pelvis was divided into two lateral cavities by a peritoneal 
fold. Each half contained a bladder, a unicornate uterus with an ovary and 
a tube, and an intestinum rectum. The vertebral column began to divide 
at the level of the third lumbar vertebra, and the two coccyges were 
quite separate. This individual has been placed amongst the double terata. 

Much more common are the cases of '-double" or septate vagina, in 
which the vulva is single, although the hymen may show two openings. 
The two canals are separated by a longitudinal septum ; in the great 
majority of cases this vertical septum runs antero-posteriorly, and the 
vaginae, therefore, are situated laterally ; in a very few cases only does 
it pass transversely, when of course the vaginal canals lie one in front of 
the other. In the latter case it must be supposed that the two unfused 
Mlillerian ducts have undergone partial rotation. It is rare, however, to 



86 SYSTEM OF GYNECOLOGY 

find the two canals exactly lateral in position and exactly equal in size ; 
one, usually the left, commonly lies a little in front of the other, and 
one is nearly always a little smaller than the other. The septum is 
composed of muscular tissue covered by mucous membrane, and has the 
consistence of the recto-vaginal septum. It varies, however, in thick- 
ness, and may even at certain places show perforations. It may extend 
the whole length of the canals, or it may be absent below and present above 
(vagina infra simplex or septa supra), or present below and absent above 
(vagina septa infra or supra simplex). In the least marked form there 
is only a ridge on the vaginal wall. In the great majority of cases the 
uterus also is double, and may be didelphous, bicornate, or septate, and 
then there is usually one cervical orifice in each vagina ; but in a few 
recorded cases the uterus was single, although the vagina was double, 
when of course only one canal gave access to a cervix. Instances have 
also been reported in which the uterus was unicornate, then one of the 
vaginae, that on the same side as the absent horn, was usually rudimen- 
tary. This last-named type, however, scarcely deserves to be termed a 
double vagina. The vulva and the hymen may be single, the vaginal 
septum stopping above the level of the ostium ; but in some cases the 
hymen shows two lateral orifices separated by a bridge of tissue. There 
may be atresia of one or both vaginal canals, leading in the adult to 
unilateral or bilateral hsematocolpos. 

Clinical Features. — Double vagina does not usually give rise to symp- 
toms prior to the occurrence of labour unless one of the canals be im- 
perforate ; then at the time of puberty blood may begin to collect 
behind the obstruction, and give rise to the troubles associated with 
hsematocolpos and haematometra. It has been stated that during preg- 
nancy the septum may be absorbed, but if it be still present at the time 
of confinement it may give rise to trouble by obstructing delivery. It 
may tear and labour go on naturally ; on the other hand, the rupture of 
it may extend to the vagina and uterus also, and fatal consequences re- 
sult. In yet other instances the septum is pushed to one side, and no 
delay in labour occasioned. Dyspareunia has been occasionally reported 
as an effect of the septate vagina. The diagnosis of the anomaly can 
be easily made by a vaginal examination, save in the cases in which one 
canal is imperforate; then the condition might easily be mistaken for a 
cyst of the vaginal wall. The siinple septum may be safely divided by 
scissors during labour. When, however, there is an accumulation of 
menstrual blood in one-half of the canal it will be necessary to open 
the sac freely, more especially if the contents are purulent, and to pack 
the interior with iodoform gauze. 

Unilateral Vagina. — In the rare cases in which only one horn of the 
uterus is developed (uterus unicornis) there is generally a similar con- 
dition of the vagina. In other words, the lower end of one of the 
Mtillerian ducts has aborted, and the vao^inal canal which exists repre- 
sents one and not both of the embryonic tubes from which it is normally 
developed. This being so, it is not surprising to find that the vagina is 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN ?>-] 

then narrow, and lies somewhat to one side of the middle line. The 
anomaly is so constantly associated with the unicornate nterns that any 
special description of it is rendered superfluons. 

Vagina Rudimentaria. — Vagina rndimentaria, like the term uterus 
rudimentarius, is a vague expression. It denotes an anomaly which 
has also been described as simple atresia and lateral atresia vaginae ; 
and clinically no line of demarcation can be drawn between it and 
complete absence of the vagina (defectus vaginae). It will therefore be 
discussed under those heads. 

Defectus Vaginae. — Patliology. — Complete absence of the vagina is a 
very rare condition — one which is met with chiefly in the allantoido- 
angiopagous twin foetus and in the sireniform monstrosity. In it no 
muscular bands are found between the bladder and rectum, otherwise 
the condition falls into the category of vaginal atresia or rudimentary 
vagina. Probabl}^ it is always associated with absence of the uterus, 
Fallopian tubes, and external genitals, and with an imperfect develop- 
ment of the mammary glands. 

Clinical Features. — Since this is a pathological, not a clinical morbid 
entity, the consideration of its symptoms will be taken with those of 
vaginal atresia, a condition from which it is undistinguishable during 
the life of the individual. 

Atresia Vaginae. — Pathology. — Vaginal atresia or imperf oration is of 
different degrees. In its most marked form no trace of the canal is found 
save a fibrous or fibro-muscular band in the tissue between the bladder 
and rectum ; in a less extreme form part of the vagina is present 
whilst the remainder is solidly imperforate ; and in a still less marked 
form there is simply a membranous obstruction or perforated diaphragm 
at one part of the passage. Again, the position of the imperf oration 
varies ; it may exist throughout the w^hole length of the canal, or it 
may be present only at the upper part, the lower part, or the middle 
part. When the upper two-thirds of the vagina are occluded it has been 
supposed that the open lower third is not truly vaginal in nature, but 
is the enlarged vestibular canal, the representative of the anterior part 
of the sinus urogenitalis of intra-uterine life. Through the failure of the 
downward progress of the Mtillerian ducts the vestibular canal has re- 
tained its early dimensions ; its depth also has probably been increased 
by attempts at coitus. When only the middle part of the vagina is 
obstructed it may be surmised that the upper canal is ]\[ullerian, or truly 
vaginal in character, whilst the lower portion is vestibular. With regard 
to the condition of the other genital organs in cases of vaginal atresia 
great differences exist. The uterus may be normal, rudimentary, or 
absent. The vulva also may be wanting or imperfect, but more usually 
it is normal and the hymen is present. The ovaries are commonly 
present. The urethral canal may be dilated, the result of attempts 
at coitus. Certain patholo2:ical changes commonly occur at puberty : 
if the uterus be present and the whole vagina imperforate, haemato- 
metra is developed and the uterus converted into a large rounded 



88 SYSTEM OF GYNECOLOGY 

sac containing blood, first the cervix and later the body becom- 
ing distended ; if the upper part of the vagina be patent, then blood 
first accumulates in it, and hsematocolpos is x^roduced, whilst hsemato- 
metra is a later development; and if the vaginal obstruction affect 
only the lowest part of the canal, hsematocolpos may be the sole 
result, the uterus remaining as a small body surmounting the dis- 
tended vaginal tumour. Hypertrophy of the vaginal walls may be 
produced, or from the accumulation of blood rupture may occur into 
one or other of the neighbouring viscera. In certain instances the Fal- 
lopian tubes also become distended and hsematosalpinx results. The 
contents of the distended vagina, uterus, or tube are usually treacly in 
character, consisting as they do of concentrated blood. After rupture 
or artificial evacuation suppuration may supervene in the sac, and 
pyocolpos, pyometra, and pyosalpinx be produced. 

Clinical Features. — The symptoms associated with vaginal atresia 
are chiefly those due to the accumulation of blood in some part of the 
genital canal at and after the period of puberty. In early life, it is true, 
some discomfort may be caused by the retention of mucus in the patent 
part of the canal, leading to constipation and dysuria by pressure ; but 
the special clinical features are all developed after puberty. There is, of 
course, amenorrhoea ; then gradually, unless indeed the uterus be absent, 
a swelling is developed in the lower abdominal region in which fluctua- 
tion can often be detected. There is sometimes a bulging in the region of 
the vulva and perineum. These signs are caused by the gradual accumu- 
lation of menstrual blood behind the obstruction. Severe pelvic pain is 
experienced, recurring with increasing severity at intervals of a month ; 
this is sometimes accompanied by vicarious menstrual haemorrhages from 
other parts of the body, for example, haemoptysis, or haematemesis. If the 
patient marry, cohabitation is found to be very difficult and painful, if 
not impossible. In time, however, the vestibular canal or urethra 
becomes distended, and an imperfect degree of connection is rendered 
possible; then the urethral dilatation leads to dysuria. There is of 
necessity sterility. In a case recently reported by Grandin the anomaly 
existed in several members of the same family. 

The diagnosis of the anomaly ought not to be a matter of difficulty. 
When, in a patient with amenorrhoea and monthly pelvic pain of in- 
creasing severity, an abdominal tumour, which fluctuates and gradually 
enlarges, is discovered, the presence of vaginal atresia may be suspected ; 
and when, in addition, it is found on examination that the vagina is 
blocked either near its orifice or at its upper part, the diagnosis may be 
safely made. Further examination by means of rectal touch, aided by 
the presence of a sound in the bladder, abdominal palpation, and vaginal 
touch (when the lower part of the vagina is patent), is chiefly under- 
taken with a view to finding out the extent of the atresia and the con- 
dition of the uterus and ovaries, so that proper treatment may be 
adopted. In carrying out this investigation it will be well to give 
the patient chloroform. The line of treatment will be largely decided by 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 89 

the extent and position of the atresia, by the state of the internal genital 
organs, by the presence or absence of retained blood, and by the circnm- 
stances of the patient. In the cases in which there is well-marked vaginal 
atresia with absence of the uterus, but with the presence of functionally 
active ovaries, as shown by recurring severe pelvic pain, the operation of 
oophorectomy has been recommended and successfully carried out 
in several instances. AVhen, on the other hand, there is a more or 
less normal uterus, associated with hsematocolpos, entirely different 
operative interference is indicated. It is not wise to leave the blood- 
accumulation to nature ; for rupture of the sac, even when it occurs 
through the vagina, is seldom safe in its immediate or satisfactory in its 
ultimate results. An incision ought to be made into the sac and the con- 
tents evacuated under strict antiseptic precautions. If the atresia be 
slight, and situated low doAvn in the canal, the evacuation may be easily 
and safely carried out ; but if a large part of the vagina be atresic, diffi- 
culties and dangers are met with. Dissection must be carefully per- 
formed with a sound in the bladder and a finger in the rectum as guides ; 
and the handle of the knife should be freely used in order to avoid wound- 
ing neighbouring organs. When the dissection has nearly reached the 
blood-sac, as determined by rectal touch, a trocar should be introduced 
to evacuate the fluid, and then the cavity should be laid freely open, 
washed out with antiseptic lotion, and plugged with iodoform gauze. 
If it be found that the accumulation of blood is in the interior of the 
uterus, then the same method of procedure must be followed, with 
even closer attention to antisepsis. Puncture through the bladder or 
rectum is not an operation to be recommended. 

When in a married woman there is vaginal atresia, but no hsemato- 
colpos or hsematometra, operative interference need not be urged unless 
the patient herself anxiously desires it. Then the question of the advis- 
ability of trying to create an artificial vagina will arise. It has been 
suggested that the uretha should be dilated to allow of coitus ; but the 
proposal has not been received Avith favour, and it would have been sur- 
prising if it had. The creation of an artificial vagina between the 
bladder and rectum is a difficult operation, requiring a great deal of 
careful dissection ; and it is followed in many cases by disappointing 
results. If it be attempted, an H-shaped incision should be made in the 
vulvar region, and then, by means of the finger rather than the knife, a 
cavity of sufficient depth should be formed ; this cavity must next be 
lined by mucous membrane and skin taken from neighbouring parts and 
sutured into position ; it must then be stuffed with iodoform gauze, and 
kept open afterwards by a wooden cone-shaped pessar}^ At a later 
period the canal is kept open by coitus. A slower method of forming 
the vagina is by means of electrolysis, and Le Fort has reported a suc- 
cessful case treated in this manner. Of course it must be borne in mind, 
that as the uterus is either absent or rudimentary, which is demonstrated 
by the absence of a blood accumulation, the operation is undertaken solely 
to allow the patient to perform her part in the act of coitus. This being 



90 SYSTEM OF GYNECOLOGY 

the case, it is no matter for wonder that certain gynaecologists have not 
favoured any operative interference in such cases. 

Atresia Vaginae Lateralis. — Pathology. — It has been already noted 
under the head of Septate Vagina that one of the canals may be imper- 
forate at its vulvar end, whilst one of the uterine orifices opens into it 
above. In this way a lateral vaginal pouch or sac is formed, atresia 
vagince. lateralis. Menstrual blood may collect in the sac and distend it, 
giving rise to the condition known as lateral hsematocolpos ; suppuration 
may also occur in it — lateral pyocolpos. The half uterus with which 
it communicates may likewise be distended with blood or pus (lateral 
hmmatometra or pyometra). This vaginal anomaly is nearly always situ- 
ated on the right side (Puech). 

Clinical Features. — As in other vaginal anomalies, symptoms do not 
arise till after puberty, when the gradual dilatation of the lateral vaginal 
sac gives rise to dysmenorrhoea, pain in the back, dysuria, and pain on 
defascation. Vaginal examination reveals an elastic tumour on one side, 
which may be confounded with pelvic haematocele ; but may usually be 
distinguished by its position and gradual increase in size. Eupture 
may spontaneously occur, either of the vaginal or uterine septum, and 
dark syrupy blood or pus be discharged. This is usually followed by re- 
accumulation in the sac, by an increase in the severity of the symptoms 
and possibly the supervention of pelvic peritonitis and even of death. 
The treatment, therefore, ought to be free incision, washing out of the sac 
with an antiseptic solution, and in many cases excision of the sac wall. 

Winckel has pointed out that inversions or prolongations of the 
vaginal mucous membrane may be met with, and may extend into the 
muscular layers of the wall and even into the paravaginal cellular tissue. 
These pockets have thin, smooth walls-, may be from 1 to 1\ inch in 
length, and must not be confounded with lateral vaginal atresia. 

Stenosis Vaginae. — Pathology. — The vaginal canal maybe abnormally 
or unusually narrow. The association of this anomaly with the uterus 
unicornis, and with atresia vaginae lateralis, has been referred to ; but it 
may also occur in connection with the uterus foetalis, or even with a 
normal organ. The stenosis may affect the whole vaginal canal, or may 
be present at certain points only. In the latter case it is probably due 
to adhesive colpitis occurring in foetal life or in the young infant. The 
narrowing may be circular, diagonal, or in spiral ridges. The so-called 
supplementary hymen is probably of this nature. The condition is 
closely allied to if not identical with transverse complete or perforated 
diaphragms in the vagina. 

Clinical Features. — If the stenosis be slight it may give rise to no 
inconvenience ; for coitus, or labour if coitus fail, usually serves to dilate 
the canal completely. In more severe cases it may be necessary to resort 
to artificial dilatation, incision, or even excision of the constricting bands. 
Hseraatocolpos is seldom, if ever, a result of vaginal stenosis if the dia- 
phragm be complete. Eupture of the canal may, however, occur in 
labour unless the obstruction is incised. 



MALFORMATIOWS OF THE GEXITAL ORGANS AV J V OMAN 91 

Abxoemal Commuxicatioxs of the Vagix'A. — The vagiua may 
open into the rectum through an imperfect development of the recto- 
vaginal septum, which normally intervenes between the two canals. 
Further, the canal may communicate by a small orifice with the 
urethra. Most of the cases of abnormal communication of the vagina 
with the rectum, urethra, and bladder are not really vaginal, but ^-ulvar 
anomalies ; being true instances of persistence of the cloaca of embry- 
onic life, or of the sinus urogenitalis. They will be described amongst 
the malformations of the vulva. Very rarely, however, cases of con- 
genital ano-vaginal and vagino-urethral fistula have been described. In 
these instances the anus and rectum and the urethra are normally formed, 
and the ^NEilllerian vagina is present at the level of the fistulous communi- 
cations. In these cases the vagina may be septate. Caradec reported an 
example of this anomaly in which there was a communication between 
the rectum and vagina, the anus and rectum being normal ; and Tordyce 
recently described a new-born infant with foetal peritonitis, in which each 
of the two halves of a double vagina opened by a small aperture into the 
urethra. In the latter case both vaginal canals were atresic inferiorly. 

Malformatiox's of the Vulva. — In considering the malformations 
of the ovaries, tubes, uterus, and vagina, it has been found most con- 
venient to discuss first the anomalies of these organs separately, and then 
to refer to those combinations of the anomalies which are most commonly 
met with. Thus unilateral absence of the Fallopian tube was first de- 
scribed separately, and it was pointed out later that it was usually 
associated with a uterus unicornis and a unilateral vagina. In dealing 
with the malformations of the vulva, however, this plan is not so useful, 
for now we have to do rather with groups of anomalies than with single 
ones. Thus, whilst something must be said regarding abnormalities of 
the clitoris, labia, and hymen, our main attention will be turned to such 
associations of defects as are found in the cloacal conditions, and in the 
cases of so-called hermaphroditism. 

Double Vulva. — The anomaly to which the name double ^-ulva may 
be correctly applied is a very rare one. In the case of Katharine Kauf- 
mann, already referred to under the head of '•' double vagina,'' there were 
two well-marked vidvae separated by a raphe. There were on each side 
two labia majora and minora, a clitoris, hymen, urethra, and anus. ^More 
recently Chiarleoni has reported a less well-marked case in a living infant, 
thirty-three months old. In this child there were also two vulvar aper- 
tures, of which the left lay somewhat obliquely ; but the anus was 
imperforate, and the condition of the internal organs was not ascer- 
tained. The cases of Blanche Dumas and of Mrs. B. ^reported by Wells) 
might be cited as examples of double vulva; but in them there were 
supernumerary lower limbs. 

Def actus Vulvae. — Comx)lete absence of the vulva (clefectv.s or atresia 
vuh'ce) is an anomaly met with only in non-viable foetuses, chiefly of the 
acephalic aud sympodial types. The skin passes without any irregularity 



92 



SYSTEM OF GYNECOLOGY 



or solution of continuity from the symphysis pubis to the coccyx. In 
such a case the anus is absent ; but this is not constant, for in some 
instances an anal orifice has been found. Internally the rectum, bladder, 
and genital ducts may all open into one cavity — persistence of the cloaca ; 
in other cases the recto-vaginal septum has developed, but the bladder 
and genital ducts have a common termination — persistence of the sinus 
'urogenitaUs. During foetal life an accumulation of urine in the bladder 
and genital canals takes place, and the infant shows at the time of birth 
considerable abdominal distension from this cause. Cases of so-called 




~%^ %,''^- 




yf- iv. 3:a- 



^\ 1 



Fig. 3T. — Atresia vulvii' superficialis. (After Rauschning-.) 



absence of the vulva in the adult woman are probably instances of the 
anomaly next to be described, atresia vulvm superficialis. Def ectus vulvae 
in the strict sense of the term has no clinical importance. 

Atresia Vulvffi Superficialis. — Pathology. — The term superficial vulvar 
atresia may be applied to those cases in which, on account of adhesion 
of the labia majora or minora, there is an apparent absence of the vulvar 
cleft (Fig. 37). Usually the occlusion is not complete, for a small orifice is 
commonly found near the root of the clitoris through which the menstrual 
fluid and urine escape. The anomaly may be present at birth, or may be 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 93 

developed in infancy. In both cases it is doubtless due to adhesive 
vulvitis which leads to a glueing together of the labia. 

Clinical Features. — In early life there may be difficulty in micturi- 
tion. After puberty the escape of the menstrual flow may be impeded, 
but haematocolpos does not usually result. After marriage the labial 
adhesion will prevent coitus, but not necessarily impregnation. It is 
possible on a superficial examination that the condition may be mis- 
taken for atresia vulvae. It is usually easy to separate the labia by 
traction ; but if this fail, a sound should be passed in through the an- 
terior opening and a careful dissection made down to it. Attempts at 
coitus may be sufficient to break down the adhesion. 

Vulva Infantilis. — In the adult the vulva may have preserved its 
infantile type and characters. This anomaly is usually associated with 
defective development of the uterus and ovaries, and with such sys- 
temic disorders as chlorosis. Its clinical importance is small compared 
with that of the associated defects ; but the existence of an infantile 
vulva may have some value as an indication of imperfect development 
of the internal genital organs. 

Abnormal Commuxications of the Vulva. — It will be remem- 
bered that during development there is a time when the allantois 
(bladder), Mlillerian ducts (vagina), and rectum all open into a common 
cavity, which in its turn opens on the surface of the body, and is called 
the cloaca. Normally this condition is transitory ; but in certain cases 
it is permanent, and thus the anomaly known as atresia ani vaginalis 
or vulvar anus is produced. In other cases development has advanced 
a stage further before it is arrested ; the perineal partition has grown 
downwards and separated the rectum, which now opens externally at the 
anus, from the rest of the cloacal cavity, which is now known as the uro- 
genital sinus. The persistence of the urogenital sinus, into which bladder 
and genital ducts open, gives rise to the anomaly known as hypospadias 
in the woman. Female epispadias, a somewhat puzzling and very rare 
malformation, may also be described here. 

Atresia Ani Vaginalis (Anus Vulvalis). — Pathology. — The term '^per- 
sistent cloaca " ought, perhaps, to be given to this anomaly rather than 
the cumbersome and not strictly accurate expression "atresia ani 
vaginalis." ''Anus vulvalis,''^ " a7ius vaginalis,''^ and "anus vulva vagi- 
ncdis,^' are also names which have been applied to this malformation. 
Apparently the normal anus is absent, and the rectum opens into the 
vagina or the vulva (Fig. 38). Strictly, however, by imperfect down- 
growth of the perineal partition, the rectum opens not into the vagina 
or vulva, but into the urogenital sinus. The Mlillerian ducts have not 
yet grown downwards to form the lower part of the vagina. What is 
commonly regarded as vagina is, therefore, not truly so, but is the canal 
or sinus which precedes the development of the vagina. In the com- 
munication of the rectum with this sinus there is, therefore, a persist- 
ence of the cloacal sta^re. 



94 



SYSTEM OF GYNECOLOGY 



Clinical Features. — The chief symptom of this anomaly is the pas- 
sage of the faeces through an opening either in the neighbourhood of 
the vestibule or in that of the posterior commissure. In some instances, 
when there is a sphincter, the patient has control over the faeces ; but in 
other cases there is no such control. In the latter case the external 
genitals, which are kept constantly moist, are apt to be sore. So uncom- 
fortable is the patient thus rendered, that she gets into the habit of 
inducing constipation to render the emptying the bowels a weekly instead 
of a daily act. When there is control over defsecation there is not any 
pressing need for operative interference; but the sinus urogenitalis 
ought to be douched after each motion. When, on the other hand, there 
is faecal incontinence it will be necessary to operate, and the age when 




Fig. 38. — Anus vulvalis. (After Dwight.) 



interference is most likely to be successful is that of fifteen years or later, 
when the faeces are fully formed and the tissues can be more easily 
moulded. The usual operation consists in the passage of a probe through 
the fistula, and the bringing of it out in the position where the anal 
aperture ought to be. The parts between the probe and the skin 
surface are then to be divided, and the rectum pulled down and sutured 
into position. As, however, by this means a permanent cure can very 
rarely be obtained, Buckmaster has recently advocated a modification 
of the operation. He advises that the probe should be brought out, 
not in the position where the anus should be, but in front of it, just 
above the levator ani muscle. Then the tissues above the probe are to 
be divided, and the rectum drawn to the skin and fastened there, but 
without strain. The raw surfaces must then be sewed together. At a 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 95 

later period the fibres of the levator ani are to be sx^lit, as are those of 
the rectus muscle in gastrostomy, in order to get a good sphincter. It 
remains to be seen whether this method of operation will yield more 
satisfactory results than the older one. 

Persistent Urogenital Sinus (Hypospadias in Woman) . — Pathology. 
— In one sense it is incorrect to speak of hypospadias in the woman 
as an anomal}^, for the normal woman, as regards her external genitals, 
may be called a hypospadiac man. There is, however, a malfor- 
mation of the female genitals to which this name has been commonly 
given. Properly speaking, it is a persistence of the urogenital sinus ; 
the urethra appears to open into the vagina ; but what is regarded as 
vagina is really sinus urogenitalis. Through a common opening at the 
base of the clitoris, which, it may be remarked, often shows hypertrophy, 
both the urine and the menstrual fluid escape. The perineum is normally 
formed, and the rectum opens separately behind it at the anus. Thus 
the condition differs from the persistent cloaca of atresia ani vaginalis. 
Pozzi describes two varieties, differing in degree, of hypospadias in the 
female subject. In one, which represents the minor degree, the vestibular 
canal is long and narrow, and receives the opening of the urethra and 
vagina fairly high up. Very frequently this type is accompanied by a 
hypertrophy of the clitoris, and thus a condition of parts is produced 
which may give rise to some doubt as to the sex of the individual. In 
the second degree, which may be called hypospadia proper, the uro- 
genital canal has disappeared ; but the lower part of the allantois, which 
ought to have been changed into the urethral canal, has been included in 
the formation of the bladder. There is thus absence of the urethra, and 
the vagina and bladder open together into the vestibular canal ; so that 
it appears as if the bladder opened directly into the vagina. Cases of 
this kind have recently been reported by Strong and Frank. There will 
be incontinence of urine as a symptom. 

Epispadias in Woman. — Patliology. — Epispadias, as a defect of the 
upper wall of the urethra is called, may occur alone, or it may be 
associated with malformations of the bladder and anterior abdominal 
wall. In the former case the urethra is seen as an open groove 
passing upwards in the position of the vestibule, and disappearing 
under the symphysis pubis, to end directly either in the bladder, or in 
the upper and closed part of the urethra; for the defect may be 
present only in part of the canal. On each side of it lies one-half 
of the split clitoris, and attached to each half is the upper end of one 
labium minus. The labia majora may unite normally in front or may 
diverge. The bladder is closed in anteriorly, and there is usually no 
separation of the symphysis pubis ; it is, however, broader than normal. 
The growth of hair in the median line of the mons veneris may be defec- 
tive, as in a case of female epispadias seen by myself. The bladder 
cavity is commonly diminished in size. In the other form of epispadias 
the anomaly is complicated by ectopia vesicae (extroversion of the bladder) 
and by a failure of union of the arcus ossium pubis. In this case the 



96 SYSTEM OF GYNAECOLOGY 

upper ends of the labia majora are wide apart, and the urine escapes 
directly from the ureters. Sometimes it is not the bladder which is thus 
open to the front, but the cloaca — development not having proceeded so 
far as to form a separate bladder. Intermediate types may be found 
between those two varieties, the simple and the complicated ; and these 
serve as connecting links. It is with the first variety, however, that 
we have here specially to do. Epispadias is much rarer in the female 
than the male subject — a circumstance which has not yet found a 
satisfactory explanation. Whether the anomaly be due to the rupture of 
parts already fused together, or to the failure of union of structures which 
normally grow together, has not yet been definitely settled. Durand 
seems to connect it with an imperfect formation of what Tourneux terms 
the " bouchon cloacal." 

Clinical Features. — The most important clinical manifestation of 
uncomplicated epispadias is incontinence of urine. The incontinence is 
not usually complete ; but any sudden movement or change in position is 
followed by a gush of urine from the small bladder. As a result the 
external genitals are kept constantly wet, erosions soon appear upon them, 
and the condition of the patient is most distressing. Menstruation, how- 
ever, commonly occurs normally, and the woman may become pregnant 
and bear a child. The cure of the condition is, therefore, urgently called 
for, and by paring the edges of the parts, and uniting them by sutures, 
a good result is sometimes obtained. In many instances, however, the 
operation fails for want of sufficient tissue, or on account of breaking 
down of the union artificially brought about. In such cases we have to 
fall back upon the use of a carefully fitted urinal, by means of which 
the patient's condition is rendered bearable. This was all that could 
be done for the case seen by me. 

Malformations of the Clitokis and Labia. — Pathology. — It has 
been shown in the preceding pages how the vulva may be malformed 
in all its component parts ; but it must now be added that each of the 
external genital organs may alone be the subject of an anomaly. 
The clitoris, for example, may be entirely wanting. This happens 
sometimes in connection with epispadias ; but it is then more usual 
to find it bifid. Possibly split clitoris in the female is homologous 
with the rare cases of bifid or double penis in the male subject. 
In some cases the clitoris is found to be poorly developed, but it 
is more common to observe hypertrophy of it. This enlargement is 
doubtless more often acquired than congenital, and is then associated with 
self-abuse ; but it may also be present at birth, usually in association 
with persistence of the urogenital sinus, or with uterine malformations. 
When hypertrophy of the clitoris is also combined with labial hernia 
of the ovaries, the resemblance which the individual bears to the male 
type is very marked. 

The labia majora may be absent, but this defect is nearly always 
associated with ectopia vesicae. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 



97 



They may also be adherent to each other, as has been already pointed 
out under the head of atresia vulvae superficialis, or conglutinatio labi- 
orum. The labia minora may also be glued together, and probably this 
accounts for some of the cases in which they were said to be wanting ; 
they may be truly absent, nevertheless, in connection with epispadias. 
. It has been stated that they may be increased in number, two or three 
folds having been found in place of one ; it is quite certain that they 
may be increased in size, and the deformity called the '• Hottentot apron " 
is well known. 

Clinical Features. — Enlargement of the clitoris and labia gives rise to 
irritation in the neighbourhood of the external genitals, and may thus be 
the cause of self-abuse and of nervous troubles. On this account it may 
be necessary to amputate the clitoris, or to excise the nymphse. In a 
case of my own great benefit followed the excision of the labia minora in 
a highly neurotic girl, who was thus restored from a state of chronic 
invalidism to one of health and usefulness. 

Malformatioxs of the Hymex. — Many of the malformations of 
the hymen have little clinical importance, although they are all of 
interest from the pathological standpoint, and some of them have 
a bearing upon medico-legal questions. There is as yet no general 
acceptance of any one theory of the mode of development of the 
hymen ; some writers assert that it is vaginal, others that it is vulvar 
in origin : but as it may be present when the vagina is absent, and 
may even be found in hypospadiac males, the facts are strongly in 
favour of the latter theory. Indeed, Pozzi, by whom these facts have 
been prominently enunciated, regards them as conclusive. At any rate, 
the hymen is to be looked upon, not as a " fixed " organ, but as a devel- 
opmental remnant; and it shows, therefore, a very large number of 
small anomalies as regards structure, form, and position. It consists 
really of three parts, which Pozzi has named hymen proper, pad of the 
meatus urinarius or urethral hymen, and male bridle of the vestibule. All 
these parts I have repeatedly been able to recognise in the new-born 
infant ; although in the adult they are not very distinct. It would seem 
that the urethral hymen, like the hymen proper, may present abnormal- 
ities ; and in an infant at birth I have seen an occlusion of the meatus 
urinarius, by what I regarded as a fusion of the two lateral parts of the 
pad of the meatus, or hymen urethrse. 

Double Hymen. — The cases of double hymen which have been 
reported are probably errors of interpretation. What is called a supple- 
mentary hymen is usually a perforated diaphragm in the vagina a little 
above the level of the normal hymen. Two or even three of these 
diaphragms may exist, and they are doubtless due to adhesions formed 
between the vaginal walls in foetal life. Of course in the rare cases of 
double vulva there may be two hymens, but this is not what is usual'ly 
meant by " double hymen." 

Absence of the Hymen. — Absence, like duplication of the hymen, is 



98 SYSTEM OF GYNECOLOGY 

an anomaly whose occurrence is not well established. In the infant at 
birth the membrane often consists of two pouting lateral folds which 
may easily be mistaken for the labia minora ; and in this way the notion 
arises that the hymen is absent. Further, in certain cases, especially in 
the negro race, the hymen is situated deeply, because the vestibular 
canal is longer than normal ; and here again the membrane may seem 
to be wanting. The medico-legal bearing of these facts in connection 
with the question of rape is evident. 

Atresia Hymenalis. — Pathology. — The occurrence of im perforation of 
the hymeneal membrane is probably not nearly so common as the large 
number of reported cases would seem to show. Undoubtedly genuine 
examples of atresia of the hymen are occasionally met with 5 lout in the 
majority of the recorded cases there is evidence to lead us to suspect that 
the membrane supposed to be hymeneal was really the blind end of the 
Mlillerian vagina. It is often possible, as Matthews Duncan and others 
have shown, to find the normally perforate hymen pushed backwards 
and hidden to some extent by the bulging of the vaginal sac. Strictly 
speaking, cases of hymeneal atresia are often instances of atresia of the 
lower part of the vagina ; or, as some prefer to name it, of the retro-hymen. 
In another group of cases adhesion of the labia minora gives rise to an 
appearance resembling atresia of the hymen ; and it is only when the 
labial attachment has been divided that the hymen is seen lying beneath. 
The pathological results of all these conditions are the same : there is 
retention of vaginal mucus in infancy, and of menstrual fluid in later 
life, with consequent occurrence of hsematocolpos. 

Clinical Features. — In the position of the vaginal orifice is found a 
bulging membrane, sometimes of a bluish colour, which in some degree 
resembles the intact bag of membranes in a labour case, and has even 
been mistaken for it. This swelling has gradually increased from the 
time of puberty, and its appearance has been accompanied by colicky 
pains recurring with increasing severity at intervals of a month, and by 
the absence of the menstrual discharge. Sometimes, also, the evacuation 
of the bladder and bowels has been rendered difficult and painful ; and in 
a few instances there have been vicarious menstrual haemorrhages. In 
advanced cases a fluctuating abdominal tumour has appeared, the result 
of distension of the vagina with blood. On the top of this swelling a 
small hard mass can sometimes be detected ; this is the undistended 
uterus. In other cases this organ also has become a blood-sac, and in 
such cases hsematocolpos and hsematometra coexist. 

Operative interference is always required in these cases, for spon- 
taneous external rupture is uncommon ; even when it occurs it is un- 
satisfactory, the evacuation being incomplete, and often followed by 
suppuration in the vaginal cavity. It used to be the custom to puncture 
the imperforate hymen at one sitting, and then later to make a crucial 
incision, and fully evacuate the contents ; for it was thought that the 
sudden escape of the vaginal contents might be attended by dangerous 
results. But this method is apt to be followed by suppuration ; and it is 



MALFORMATIONS OF THE GEXITAL ORGANS IN WOMAN 99 

1)6 st to make first a small incision so as to allow the blood slowly to 
escape, and then at the same sitting to enlarge the opening, to wash out 
the canal thoroughly with an antiseptic lotion, and finally to pack it 
firmly with iodoform gauze. 

Anomalies in the form of the Hymen. — Many anomalies in the 
form of the hymen may be met with, but they are of comparatively 
little practical importance. Instead of having its normal crescentic 
or semilunar shape, it may retain its infantile character; it then 
shows two lateral projecting lips, which have sometimes been mis- 
taken for the nymphas ; it is then called labiated or infandihuliform. 
Sometimes notches occur naturally in the membrane, which then is called 
the hymen denticulatus ; it is necessary to remember the occurrence of 
these folds or notches, and to distinguish them from the rents produced 
by coitus or labour. Rarely the fimhriatpd hymen is met with. The 
orifice is usually situated nearer to the anterior than to the posterior 
border of the membrane ; but occasionally it is quite central — hymen 
circidaris. Further, the opening may be very large {falciform), or there 
may be two orifices of equal size, situated laterally {hymen septus). Yet 
another form is that in Avhich there are two apertures of unequal size, 
and situated irregularly {hymen bifenestratus, hymen biforis). A very 
uncommon type is the cribriform, in which there are many small holes 
in the membrane {hymen cribriformis). 

Anomalies in the structure of the Hymen. — Pathology. — The hymen 
may be abnormally thick, abnormally firm or rigid, or abnormally vascular. 
It may also show combinations of these anomalies. Thus it may be 
both thick and vascular, or both rigid and fleshy. To a certain extent 
these states may be regarded as due to a persistence of the foetal char- 
acters of the membrane, and they are of some clinical importance. 

Clinical Features. — Abnormal rigidity of the hymen maybe the 
cause of dyspareunia, or it may entirely prevent penetration in the act 
of coitus. In a case seen by m^^self it was found necessary to excise 
the hymen of a newly married patient before complete connection could 
be accomplished by her husband. In other cases pregnancy occurs not- 
withstanding the unruptured state of the hymen ; and the presence of 
the membrane may protract labour, or, if it be torn, may cause a deep 
laceration also of the perineum. Cases have even been reported in which 
the hymen has been found intact after a miscarriage; but in these 
instances the membrane has probably been abnormally elastic, rather than 
abnormally rigid. The importance of the occurrence from the medical 
jurist's standpoint is manifest in connection with the question of chastity. 
Abnormal vascularity of the membrane is also an anomaly of some im- 
portance, for, on the first occasion of coitus, it may be the cause of alarm- 
ing or indeed of dangerous haemorrhage. All these structural malfor- 
mations of the hymen are more easily imderstood if it be granted, as 
Pozzi aifirms, that the hymen is the homologue of the corpus spongiosum 
of the male. 



SYSTEM OF GYNAECOLOGY 



Hermaphroditism 

The exact meaning of tlie word " hermaphrodite," as applied to the 
human subject, has undergone a change. Whilst the older writers applied 
the term to individuals whom they regarded as possessing the organs 
of both sexes in an anatomical and in a physiological sense, modern 
authors have come to use the name rather to indicate subjects whose 
true sex is doubtful. Malformations of the genital organs, giving rise 
to doubts as to the true sex of the individual, have attracted the 
attention of observers from the earliest periods of the world's history, 
and, as I have elsewhere shown (327), records of such cases have been 
found on the brick tablets of the ancient Chaldean libraries. In E,ome 
individuals of doubtful sex were destroyed. In the East, on the other 
hand, there is reason to believe that they were deified. According to 
the Talmud, Abraham was a hermaphrodite, and so, according to many 
authors, was Adam. 

In one sense the human embryo at a certain period of its existence 
may be regarded as hermaphrodite. There is a stage in development 
when it is impossible to state whether the sexual gland will become an 
ovary or a testicle ; whether the Mlillerian or the Wolfiian ducts will 
atrophy ; whether the genital tubercle will become a penis or a clitoris. 
The embryo is then, so far as is known, potentially of either sex, and 
awaits the action of some force to determine which sex is to predominate. 
It is easy to understand how morbid influences, brought to bear upon the 
embryo at or about the time when it is passing from its sexually indiffer- 
ent stage into one of differentiation, may so upset the normal process of 
development as to produce an individual with, for example, testicles and 
a uterus. It is, however, a matter of great difficulty to imagine a con- 
dition of affairs which would give rise to the presence of a testicle and 
an ovary on the same side ; for, so far as is known, the sexual gland may 
ibecome either a testicle or an ovary, but not both. In the Mlillerian 
and Wolffian ducts, on the other hand, we have to do with two sets of 
structures, one of which normally atrophies and the other develops ; but 
abnormally both may persist in a more or less fully formed condition. 
As a matter of fact, it is very doubtful whether a genuine case of the 
coexistence of testicles and ovaries in the human subject has ever been 
reported ; whilst instances of pseudo-hermaphroditism, as they have been 
called, are far from rare. Still, it is never safe to say that the occur- 
rence of any particular teratological combination is impossible ; and if 
we bear in mind that true hermaphroditism has been met with in fish, 
amphibians, and even in the goat and pig, it may be that some observer 
will yet record an undoubted case in the human subject. 

Writers have classified cases of hermaphroditism in various ways. 
Klebs, for example, divides them into two groups : true hermaphroditism, 
or hermapliroditismus verus, in which ovaries and testicles coexist; and 
pseudo-hermaphroditism, or hermaphroditismus spurius, in which, along 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN loi 

with either ovaries or testicles, there are found some of the genital organs 
of the opposite sex. Pseuclo-hermaphroditism, again, he divides into mas- 
culine or feminine, according as testicles or ovaries are present ; whatever 
may be the state of the other reproductive organs. Pozzi to some extent 
modifies this scheme of classification. He arranges all the cases in three 
groups: partial iiseudo-liermaphroditism, in ^xhioh. one sex obviously pre- 
dominates, only a few of the peculiarities of the other being present; 
pseudo-hermaphroditism properly so-called, including a large number of 
cases chiefly of the variety known as male hypospadiacs ; and sup>iJosed true 
hermaplirodUism, in which both kinds of sexual glands have been regarded 
as present. It does not seem theoretically necessary to make a distinction 
between pseudo-hermaphroditism and the partial variety, although practi- 
cally the separation may be of value. The scheme here adopted is that 
which groups all the cases into pseudo-hermaphrodites and supposed true 
hermaphrodites, with certain subdivisions which will be stated under 
each head ; and I have added a new variety, or rather have resuscitated 
an old one, in which the external genitals of both sexes seem to be pres- 
ent in the same individual. Something will first be said regarding the 
cases which have been reported as instances of true hermaphroditism, 
and then the large group of the pseudo-hermaphrodites will be considered. 

Supposed True Hermaphroditism. — Klebs has divided true her- 
maphroditism into three groups : bilateral (or vertical), in which an ovary 
and a testicle are found on both sides of the body ; imilatercd, in which 
an ovary and a testicle coexist on one side, whilst on the other side 
is an ovary or a testicle, or neither; and lateral (or alternate), in 
which the female gland is present on one side and the male on the 
other. In the present state of our knowledge this subdivision is, as 
regards the human subject at any rate, quite unnecessary; for well- 
authenticated examples of the first and second varieties are wanting, 
and even of the third type the instances that have been reported are 
not altogether convincing. All the cases in which there is no report of 
a post-mortem examination are, of course, useless in classification ; for 
the whole value of such reports consists in the recognition by the naked 
eye and microscopically of two glands, one of which must have the char- 
acters of the ovary and the other those of the testicle. It cannot even 
be safely asserted, as was done by Rokitansky in the case of Catherine 
Hoffmann, that the allegation of a menstrual discharge is a proof of the 
existence of ovaries. Indeed there is evidence to show that the adult 
subjects of these abnormalities will intentionally mislead the observer 
concerning such phenomena as menstruation. 

The case reported in 1870 by C. L. Heppner of St. Petersburg has 
been regarded by many authors as a genuine example of hermaphro- 
ditismus verus bilateralis ; for in it were described a uterus with ovaries 
and tubes, and on each side also a rounded body in the neighbourhood 
of the ovary which had the microscopical characters of the testicle. 
The external organs were like those of the woman. Now, with regard 



SYSTEM OF GYNECOLOGY 



to this case, it must be borne in mind that the parts had been pre- 
served for some time in spirit before they were examined ; and that 
the microscopical appearances of the so-called testicles might easily 
be regarded as those of immature or undifferentiated ovaries. The 
arrangement of tubes packed with cells, as depicted by Heppner, 
seems to me to suggest a mal-developed ovary as much as a testicle. 
The probability is that the so-called testicles were really accessory or 
constricted ovaries — bodies which, as has already been stated, often 
show a structure made up almost entirely of Pfliiger's tubes. The case 
examined by H. Meyer, and reported by Cramer in 1857, is one of a 
considerable number in which true hermaphroditism of the lateral 
variety was alleged to be present. In this instance there were a rudi- 
mentary uterus and a vagina, and, on tlie right side, a normal ovary, 
parovarium, and tube. On the left side were a tube, a parovarium, and 
a body herniated in the left scrotal sac, and supposed to be a testicle. 
Cramer does not give the detailed microscopical appearances of this 
body ; but it seems more rational to regard it as an ovary, possibly in a 
rudimentary state, which had descended into the left labium, than as a 
testicle. In conclusion, it may be said that science still awaits the 
publication of a case in which all competent observers will be able to 
recognise the existence in the same individual of two glands, one of 
which is undoubtedly ovarian and the other testicular in nature. In the 
meantime it seems impossible to conceive how the impulse that deter- 
mines sex can be so divided in its action as to turn one sexual gland 
into an ovary and the other into a testicle. 

PsEUDO-HERMAPHRODiTisM. — Patliology. — Cascsof pseudo-liemiaph- 
roditism are not uncommon, as a glance at the appended bibliograph- 
ical list (for the last five years) will serve to show. In many of them 
the dubiety as regards sex is evidently due to the existence of one or 
other of the anomalies of the female external genital organs which have 
been already described. In many more, however, we have to deal with 
malformations of the penis and scrotum, which have given to the exter- 
nal parts a somewhat feminine appearance. In the former group of 
cases the ovaries are present, whatever may be the condition of the 
other organs, and the individual is therefore really a female in the 
state known as jpseudo-liermapliroditismus femininus or gynandry : in 
the latter group the subject by the possession of the testicles is a 
male, however closely he may approach the other sex in appearance, 
a state known as pseudo-hermiapliroditismus mascidiims or androgyny. 
Individuals of the second kind are far commoner than those of the first. 
Each of these two varieties has been subdivided into three groups — 
internus, externus, and completus. Thus in a case of pseudo-hermaphro- 
ditismus masculinus internus there are testicles in association with 
external genitals of the male type, and a uterus, vagina, and even 
tubes. In pseudo-hermaphroditismus masculinus externus there are also 
testicles, but the external genitals and the build of the body are feminine. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 103 

Again, in pseudo-hermaphroditismus masculinus completus sen externus 
et internus there are testicles, bnt there is also a nterns mascnlinns with 
tnbes; and the external organs approach more or less closely to the 
female form. In the same way in the three varieties of feminine psendo- 
hermaphroditism there are always ovaries ; bnt in the internal type there 
are also distinct traces of the Wolffian dncts ; in the external type the 
external genitals are of the male form ; and in the complete type the 
externa] organs are masculine, and the Wolffian ducts and prostate 
gland are present. The enumeration of these varieties will have given 
the reader some idea of the morbid anatomy of pseudo-hermaphrodit- 
ism ; at the same time it must be borne in mind that some of them are 
very rare ; one of them, on the other hand — pseudo-hermaphroditismus 
masculinus externus — is, comparatively speaking, very common. 

One of the most usual arrangements of parts to which the name of 
feminine pseudo-hermaphroditism is given is that in which a woman 
presents an adhesion of the labia along with hypertrophy of the clitoris. 
When, also, there is a labial ovarian hernia on one or both sides, and 
a development of hair on the face, the resemblance to the male, at 
any rate to the hypospadiac male, becomes very striking. The vulva, 
however, may be normal, and the subject show simply an enlarged 
clitoris, a beard, and a masculine arrangement of the pubic hair, as in 
the case of Zefthe Akaira (La Donna-Uomo), recently described by Zuc- 
carelli in Italy. Examples of this kind of gynandry might be multiplied. 

Non-descent of the testicles in the male gives origin to one variety of 
androgyny. Such men are often the subjects of gynsecomastia (enlarge- 
ment of the breasts) ; and since also the penis, although perforate, is some- 
times small, and the sexual functions poorly developed (infantilism), it is 
easy to understand how doubts as to their virility may arise. A more 
common type of androgyny, however, is that caused by the existence of 
scrotal hypospadias (Fig. 39). In this case the resemblance to the female 
type of external genitals is very strong, for there is a small imperforate 
penis often fixed in position under the symphysis by adhesions ; the urethra 
opens externally near the root of the penis, and below it is a sort of 
vulvar aperture or vestibular canal which may even be of some depth, 
and may be guarded by a hymen. The external genitals in such a case 
resemble, as Pozzi graphical!}^ expresses it, those of an embryo seen under 
a magnifying glass. When it is also borne in mind that the testicles 
are either undescended or at any rate atrophic, and that the individual 
has probably been mistaken for and brought up as a girl, and has thus 
acquired feminine habits, it is easy to see how extremely difficult it may 
be to ascertain the real sex. The difficulty may be still further increased 
by enlargement of the mammae, by the absence of hair on the face and 
chest, and by the occasional discovery of a uterus ; although, of course, 
ovaries are not to be detected. Doubtless most of the cases of supposed 
true hermaphroditism have been really hypospadiac men. 

A word or two may here be said regarding a form of pseudo-hermaph- 
roditism not recognised by recent writers. In very rare instances 



I04 



SYSTEM OF GYNECOLOGY 



individuals otherwise apparently single show complete duplication of the 
vulva or of the penis. In a recent article (328) I have shown that in some 
of these cases of diphallus one penis only may be perforate, the other being 
smallj and presenting an opening below it through which urine escapes. 




Fig. 39. — Pseudo-hermaphroditism, perineo-scrotal hypospadias. (After Pozzi.) j7, Glans ; &, frsenum ; 
mu^ meatus urinarius ; oi\ vulvar orifice; hy^ hymen;/, fourchette ; pi, labia minora; gl, labia 
majora. 

Such a case might easily be regarded as an instance of the coexistence of 
both male and female external genitals ; and possibly some of the dis- 
credited accounts of persons provided with a vulva and a penis, reported 
by early writers, may have belonged to this category. Similarly in 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 105 

individuals with a double vulva tlie enlargement of one clitoris might 
give rise to a similar notion ; and probably the case of an infant, seen by 
Moostakov, in which there were on one side external genitals of the 
female type with a perforate urethra, and on the other an imperforate 
penis (?) and a scrotum without testicles, may have been of this kind. 
The condition might be called external pseudo-liermaphroditism, had not 
this name been already appropriated to another type of genital anomaly. 

Clinical Features. — Whilst in the histories of pseudo-hermaphrodites 
there are many details which are peculiar to each case, there are also some 
which are practically common to all. The error in the recognition of the 
true sex of the individual is usually made at birth and confirmed at 
baptism ; and, as a rule, it is not till the period of puberty is reached 
that doubts of the accuracy of the declaration at birth begin to prevail. 
In the case of male pseudo-hermaphrodites the error may even be per- 
petuated still longer, and the individual may be married as a woman and 
live with a husband, an imperfect form of coitus taking place per urethram. 
Usually, however, suspicions begin to be entertained at puberty when, 
in the case of hypospadiac males who have been brought up as females, 
the failure of the establishment of the menstrual function and the appear- 
ance of certain of the secondary sexual characters proper to the male sex 
give rise to doubts. At the same time, it must be borne in mind that 
even in these subjects haemorrhage simulating the menses may take place 
from the urethra dilated by coitus, and in a few instances a real catamenial 
discharge from a uterus has been noted. Further, the secondary sexual 
characters cannot be relied upon ; for mammary enlargement, rounded 
outlines, a broad pelvis, a small larynx, and a feminine distribution of the 
body-hair, may all be met Avithin male pseudo-hermaphrodites, whilst the 
secondary sexual characters of the male may coexist with ovaries. The 
habits, also, and the feelings and desires of the subj ect, will depend largely on 
the surroundings of early life, and cannot be regarded as diagnostic of the 
sex. Pseudo-hermaphrodites are generally sterile ; for the sexual glands 
are often mal-developed, and even when they are active the anomalies of 
the other organs prevent the successful accomplishment of the reproduc- 
tive act. Mental and moral weakness and even insanity are not uncommon ; 
and in the case of Alexina B., so graphically recorded by Tardieu, the 
individual, a hypospadiac male, committed suicide. Many of the so-called 
'■ degenerates " show anomalies of the genital organs. That the condition 
may be hereditarily transmitted is probable ; at any rate family prevalence 
is not uncommon, and J. Phillips has recently reported four cases of 
pseudo-hermaphroditism in one family and Lindsay has seen three. I 
am also acquainted with a case in which two hypospadiac males, the 
children of one mother, have been brought up as sisters. 

The treatment of such cases presents many puzzling problems. Law- 
son Tait's rule that every infant about whose sex there is doubt should be 
brought up as a male is a good one ; for male pseudo-hermaphrodites are 
more common than female, individuals reared as inales are not so apt to 
enter into marriage in ignorance of their sexual inability, and there is less 



io6 SYSTEM OF GYNECOLOGY 

danger in bringing up a girl among boys than a boy among girls. The 
question of the advisability of surgical interference is a difficult one. In 
a case reported by Christopher Martin, the testicles were removed from an 
individual brought up as a girl, and castration was followed by a develop- 
ment of the breasts and pubic hair ; whilst Pean records the extraordinary 
operative history of an individual whose abdomen was first opened to 
discover the sex, then an artificial vagina was made, and finally the 
abdomen was again opened and the tubes and ovaries removed. The 
division of a tight frenum in a hypospadiac male, and the separation of 
the adherent labia in a gynandrous individual, are minor operations which 
may be undertaken without hesitation ; but it is doubtful whether we 
are justified in removing the sexual glands in any case of pseudo-her- 
maphroditism, although of course the alternative procedure of making 
a redeclaration of sex is also attended with difficulty and great incon- 
venience. Possibly it may be well to consider the advisability of the estab- 
lishment of a third class of individuals, who shall be regarded as neuter. 
The medico-legal bearings of hermaphroditism are self-evident. The 
questions of identity, of paternity, of the right to exercise the franchise, 
and to enter professions open only to one sex, when the individual is one 
about whose true sex there is some doubt, all require very careful con- 
sideration and clinical investigation. Further, the legality of a mar- 
riage between a man and a hypospadiac male cannot be maintained ; 
and one between a woman and a gynander is equally against the law. 
Further consideration of these matters is not, however, necessary in a 
text-book of gynaecology. 

J. W. Ballantyne. 

RECENT REFERENCES 

Malformations of the Ovaries: — 1. Ballantynb and Williams. Structures 
in the Mesosalpinx, p. 44, 1893. — 2. For early bibliographical references vide 
Olshausen. Bie krankheiten der Ovarien, p. 12. Stuttgart, 1877. — 3. Winckel. 
Lehrbueh der Frauenkrankheiten,Y). 595. Leipzig, 1886. — 4. Colomiatti, V. Frammenti 
di embriologia patologica, p. 14:. Torino, 1880. — 5. Keppleb. Allg. Wien. med. Ztg. 
p. 385, 1880. — 6. Romans, J. Boston M. mid S. Journ. cxvii'. p. 60, 1887.— V. 
SiPPEL, A. Centralbl.f. Gi/nak. xu\. p. '305, 1SS9. — 8. Bassini. Centralbl.f. Gyndk. 
xiii. p. 640, 1889. — 9. Ballantyne, J. W. Trans. Edin. Obst. Soc. xv. p. 56, 
1890. — 10. Tait, Lawson. Diseases of Women, i. p. 277, 1889. — 11. Schantz, H. 
" Vier Falle von accessorischen Ovarien," Z)is.s. Kiel, 1891. — 12. Falk, E. Berl.klin. 
Wchnschr, No. 44, 1891.-13. Munde. Jw. Journ. Obst. xxiv. p. 218, 1891. — 14. 
Sutton, J. Bland. Surgical Diseases of the Ovaries, etc., p. 24:. London, 1891. — 15, 
Skene, A. J. C. Diseases of Women, 2nd edit. p. 450, 1892. — 16. Popoff, D. Arch, 
f. Gynaek. xliv. p. 275, 1893. — 17. Zinnis, A. La med. infant, i. p. 267, 1894. — 18. 
RuppoLT, E. ^rc7i./. G^i/n«pA:.xlvii. p.646, 1894. — 19. Dblageniere, P. Progr. med. 
2nd series, ii. p. 256, 1894. — 20. Edridge-Green, F. W. Brit. Med. Journ. p. 416, i. for 
1895. — 20a. Engstrom. Finska Idkar. handlingar, xxxvii. p. 667, 1895. — 20b. 
M'CosH, A. F. Titans. Am. Surg. Assoc, xiii. p. 481, 1895.— 20o. Lockwood, C. B. 
Brit. Med. Journ. p. 716, ii. for 1895. 

Malformations of the Fallopian Tubes: — 21. Richard, A. Compt. rend. Soc. de 
biol. iii. p. .H7, 1852. —22. Blot. Ibid. 2nd series, iii. p. 176, 1857.-23. Huter, C. 
Monats. f. Goburtsk. xxv. p. 424, 1865.— 24. Stewart, T. G. Jour. Anat. and 
Physiol, ii. p. 243, 1868.-25. Keppler. Allg. Wien. med. Ztg. p. 385, 1880. — 26. 
Colomiatti, V. Frammenti di embriologia patologica, p. 14. Torino, 1880.-27. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 107 

SiNETY, L. DE. Traite pratique de (fynecologie, p. 770, 1881. — 28. Winckel, F. 
Lehrbuch cler Frauenkrankheiten, p. 569. Leipzig, 1886. — 29. Doran, A. Trans. 
Obst. Soc. London, xxviii. p. 171, 1887. — 30. Ballantyne, J. W. Trans. Edin. 
Obst. Soc. XV. p. 56, 1890.— 31. Haultain, F. W. N. Trans. Edin. Obst. Soc. xv. 
p. 220, 1890.-32. Ballantyxe, J. W., and Williams, J. D. Brit. Med. Journ. 
Jan. 17 and 24, 1891.-33. Falk, E. Berl. klin. Wchnschr. No. 44, 1891. — 34. 
Sutton, J. Bland. Surgical Diseases of the Ovaries and Fallopian Tubes, p. 227. 
London, 1891.-35. Haultain, F. W. N. Trcms. Edin. Obst. Soc. xvii. p. 194, 
1892. —36. Amann, J. A. Arch. f. Gijnaek. xlii. p. 133, 1892.— 37. Popoff, D. 
Arch. f. Gynaek. xliv. p. 275, 1893. — 38. Ballantyne, J. W., and Williams, J. D. 
The Structures in the Mesosalpinx, p. 25. Edinburgh, 1893. — 39. ]VL4.rchand. Berl. 
klin. Wchnschr. p. 814, Aug. 27, 1894.-40. Ruppolt, E. Arch. f. Gynaek. xlvii. p. 
646, 1894.— 41. Kossmann. Ztschr. f. Geburtsh. u. Gyndk. xxix. p. 25-3, 1894.— 
42. Ferraresi, C. Ann. di. Ostet. xvi. p. 521, 1894. —43. Delageniere, P. 
Progres med. 2nd series, ii. p. 256, 1894. — 44. Sanger, M, Monatschr. f. Geburtsh. 
u. Gynaek. i. p. 21, 1895.-45. Edridge-Green, F. W. Brit. Med. Journ. p. 416, i. 
for 1895. — 46. Kube, N. N. Journ. akush. i jensk. boliez. p. 485, May 1895. — 46a. 
Penrose. Am. Journ. Obst. xjcxu. p. 2^5, lS95. — ^6b. Sanger. Centralbl.f. Gyndk. 
XX. p. 162, 1896. 

Uterus Accessorius:— 47. Skene, A. J. C. Treatise on the Diseases of Women, 
p. 29, 1892.— 48. Hollander, E. Berl. klin. Wchnschr. xxxi. p. 452, 1894. —49. 
Depage. Arch, de tocol. xxi. p. 550, 1894. 

Uterus Didelphys et Bicomis : — 50. Althen. Centralbl. f. Gyndk. xiv. p. 711, 1890. 

— 51. Paschen. Centralbl. f. Gyndk. xiv. p. 11, 1890. —52. Dudley. Am. J. 
Obst. Jan. and Feb. 1890.-53. Schuler, C. " Ueber einen Fall von Uterus duplex 
septus cum vagina septa," Diss. Kiel, 1890. —54. Gusserow. Charite-Ann. xv. p. 618, 
1890. —55. Thevard. JV. Arch, d'obst. et de gynec. v. p. 640, 1890. —56. Elbing, R. 
St. Petersb. med. Wchnschr. vii. p. 299, 1890.-57. Vasten, V. A. Bolnitsch. gaz. 
Botkina. i. p. 986, 1890.-58. Ballantyne, J. W. Tixins. Edin. Obst. Soc. xv. p. 
160,1890.-59. ScHWARz. i^mwenar^^, vi. p. 12, 1891. — 60. Broome, G. W. Weekly 
M. Rev. xxiii. p. 321, 1891.-61. Massey, G. B. Ann. Gynsec. and Psediat. iv. p. 365, 
1890-1.-62. HiRiGOYEN. Rev. obstet. et gyndc. vii. p. 133, 1891. —63. Curatulo, G. e! 
Riforma med. vii. p. 337, 1891.-64. Ciajo, A. Gazz. d. osp. xii. p. 670, 1891. — 65. 
Nitot. • Rev. obste. et gynec. vii. p. 340, 1891.-66. Layton, R. JV. Orl. M. and S. J. 
xix. p. 412, 1891-2.-67. Schwartz, F. Orvosi hetil. xxxv. p. 294, 1891.-68. 
Berlin, F. Anii. Gynsec. and Psediat. v. p. 193, 1891-2. — 69. Halter, G. Wien. med. 
Presse, xxxiii. p. 49, 1892. — 70. Tannen, A. Centralbl.f. Gyndk. xvi. p. 51, 1892.— 
71. Sachs, G. Med. Obozr. xxxvii. p. 130, 1892. —72. Burke, W. H. Brit. Med. Journ. 
i. for 1892, p. 1020.— 73. Williams, F. N. Laiicet, i. for 1892, p. 1185. — 74. 
Drujinin, I. N. J. akush. i jensk. boliez. vi. p. 239, 1892.-75. Giglio, G. Riforma 
med. viii. p. 185, 1892.— 76. Sicherer, O. v. Arch. f. Gynaek. xlii. p. 339, 1892. — 77. 
PiccoLi, G. Levatrice mod. i. p. 58, 1892. —78. Borde, L. Bull. d. sc. med. di 
Bologna, iii. 206, 1892 (3 cases). — 79. Stoll, K. Ztschr. f. Geb. und Gyn. xxiv. p. 275, 
1892.-80. RossA, E. Wien. klin. Wchnschr. v. p. 501, 1892.-81. Stewart, AV. S. 
Ann. Gynsec. and Psediat. vi. p. 150, 1892-3.-82. Currier, A. F. X. Y. Journ. Gynsec. 
and Obst. iii. p. 50, 1893. — 83. Edebohls, G. M. JV. Y. Journ. Gynsec. and Obst. iii. p. 
290, 1893.-84. Stratz, C. H. Nederl. Tijdschr. v. Verlosk. en Gynaec. iv. p. 121, 
1893.-85. BiEHL, K. Mitth. d. Ver. d. Aerzte in Steiermark, xxx. p. 103, 1893.-86. 
Kleinwachter, L. Zeitschr. f. Geb. u. Gyn. xxvi. p. 144, 1893. — 87. Cullingworth, 
C.J. Trans. Am. Gyn. Soc. xviii. p. 434, 1893.-88. Ratcliffe, J. R. Trans. Obst. 
Soc. Bond, xxxiv. p. 469, 1893.-89. Leuf, A. H. P. Med. iV^itvs, Ixiii. p. 4^.0, 1893. 

— 90. Senfft, a. Ztschr. f. drztl. Landpraxis, ii. p. 313, 1893.-91. Johnson, F. 
W. Boston M. and S. J. cxxix. p. 643, 1893. —92. Pfannenstiel, J. Festsch)nft 
. . . in Berlin, p. 330, 1894.-93. Lohlein, H. Centralbl. f. Gyndk. xviii. p. 997, 
1894.-94. Croasdale, H. T. Aw. J. Obst. p. 359, 1894. — 95. Semeleder, F. Gac. 
med. Mexico, p. 287, 1894.-96. Calderini, G. II Policlinico, p. 92, 1894. — 97. 
Burton, J. E. Liverpool Med.-Chir. J. p. 459, 1894. — 98. Gouget, A. Bull. Soc. 
Anat. de Paris, p. 24, 1894. — 99. RossA, E. Centralbl.f. Gyndk. xviii. p. 422, 1894.-100. 
Ayers, E. a. Am. J. Ob.<<t. p. 104, 1894.-101. Eustache, G. Ann. di. Ostet. p. 
336, 1894. — 102. Schuhl. Ann. de Gynec. p. 248, 1894.-103. Werder. X. O. J. 
Am. M. Assoc, p. 234, 1894.-104. Kinghorn. Montreal Med. Journ. p. 442, 1894.— 
105. Owen, R. O. Virginia Med. Monthly, p. 926, 1895.-106. Serejinsky, G. P. 



io8 SYSTEM OF GYNECOLOGY 

Journ. aJcush. p. 183, 1891. —107. Simon, M. Centralhl. f. Gyniik. xviii. p. 1313, 1894. 

— lOS. Batchelor, F. C. Intercol. Quart. J. Med. and Surg. i. p. 309, 1895. — 109. 
Arnold, E. G. E. Z^aucei, i. for 1895, p. 988. — 110. Chapuis. Lyon. med. p. 83, 1S94:. 

— 111. RossiER. Rev. med. de la Suisse roinande, p. 159, 1895. — 112. Roux. G. Arch, 
de tocol. p. 59, 1895. — 113. Swope, S. D. Med. News, p. 391, 1895. — 114. Penrose, C. 
B. Am. Journ. Obst. p. 915, 1895. — 115. Maygrier, Rev. med.-chir. d. mal. d. 
femmes, p. 353, 1895. — 115a. Mallett, G. H. N. Y. Med. Journ. Ixiii. p. 24, 1895. 
"—1156. Mettenheimer, C. Arch. f. Gynuk. 1. p. 221, 1895. — 115c. Baer, B. F. 
Am. Gyn. and Obst. Journ. vii. p. 40, 1895. — l]5d. Brull, P. Arch, de Ginecopat. 
obstet. y pediat. viii. p. 651, 1895. — 115e. Tschudy, E. Arch. f. Gyn'dk. xlix. p. 471, 
1895. — 115/. Sprigg, W. M. Am. Journ. Obst. xxxii. p. 78, 1895. — 115(7. Eustache, 
G. Journ. sc. med. de Lille, xviii. p. 313, 1895. — 115A. Goullioud. Rev. obstet in- 
ternat. Suppl. p. 251, 1895. — 115z. Griffon, V. Bull. Soc. Anat. de Paris, 5. s. ix. 
p. 520, 1895.-115;. Meerdervoort, N. J. F. P. Arch, de tocol. xxii. p. 721, 1895.— 
115A;. Spibgelberg, H. Arch. f. path. Anat. cxlii. p. 554, 1895. — 115^. Giles, A. 
Trans. Obst. Soc. London, xxxvii. p. 301, 189G. — Horn. Swayne, W. Bristol Med.- 
Chir. Journ. xiv. p. 101, 1896. 

Uterus Septus: — 116. Schramm, J. Centralbl. f. Gyndk. xiv. p. 185, 1890. 
— 117. Shtol, K. Otchet. Mar. ginek. otdiel, ]). ^1,18^1. — 11%. Scialdoni, A. Gior. 
internaz. d. sc. med. xiii. p. 534, 1891. — 119. Kleinschmidt. K. Univ.-Frauenklin. 
in Mdnchen, p. 129, 1892.-120. Fuchtenbuch, H. Diss. Strasburg, 1892.-121. 
Drake-Brockman, H. E. Brit. Med. Journ. i. for 1893, p. 1220.-122. Hallowbll, 
W. E. North-west. Lancet, xiii. p. 427, 1893.-123. Wheaton, S. W. Lancet, ii. for 
1893, p. 1562. — 124. Chrobak. Centralbl. f. Gyndk. xviii. p. 431, 1894.-125. Mert- 
TENS. Centralbl. f. Gyndk. xviii. p. 1001, 1894.-126. Werth, R. Arch. f. Gynae-k. 
xlviii. p. 422, 1895. — 127. Karra, D. A. Universitetskiya izvyestiya, p." 149, 1895. 

— 127a. Walther, H. Ztschr. f. Geburtsh. u. Gyndk. xxxiii. p. .389, 1895. 

Uterus Unicornis: — 128. Frommel. Miinchener med. Wchnschr. No. 15, 1890.— 
129. VoLL. Sitzungsb. d. j)hys.-med. Gesellsch. zu Wiii^zbia^g, pp. 30, 33, 1891. — 130. 
Skene, A. J. C. Treatise on the Diseases of Women, p. 33, 1892. — 131. Mangiagalli, L. 
Atti. d. Assoc, med. Lombarda, p. 29, 1892.-132. Tapie. Midi med. i. pp. 85, 97, 1892. 

— 133. Gessner. Centralbl. f. Gyndk. xviii. p. 824, 1894. 

Uterus Deficiens et Rudimentarius: — 134. Werner, J. Deutsche med. Wchnschr. 
No. 11, 1890. — 135. Frank, K. Ztschr. f. Geburtsh. u. Gynaek. xviii. Hft. 2, 1890.— 
136. Altmann. Centralbl./. Gyndk. xiv. p. 103, 1890. — 137. Liebmann. Centralbl. 
f. Gyndk. xiv. p. 928, 1890. — f38. Rossignol, F. Thesis. Paris, 1890. — 139. Mar- 
CHiONNESCHi, O. Pisa, 1890. — 140. Sv^^iecicki, V. Wien. med. Bl. xiv. p. 85, 1891. 
— 141. LoviOT. Bull, et mem. soc. obst. et gynec. de Paris, p. 78, 1891. — 142. Balade. 
Journ. de med. de Bordeaux, xxi. p. 85, 1891-2. — 143. Delageniere, H. Cong, franc, 
de chir. Proc.-verb. Paris, v. p. 346, 1891.-144. Snow, L. B. Med. Rec. xii. p. 41. 
1892.-145. HoFMOKL. Ber. d. k.k. Krankenanst. in Wien, p. 334, 1891.-146. 
Elischbr, J. Pest, med.-chir. Presss, xxviii. p. 274, 1892. — 147. Brettauer, J. Am. 
J. Obst. xxvi. p. 394, 1892.-148. La Torre, F. Bull. d. r. Accad. med. di Roma, 
xviii. p. 231, 1891-2.-149. Eberlin, A. Med. Obozr. xxxvii. p. 1041, 1892.- 150. 
Albertin. Province med. vii. p. 159, 1893. — 151. Gelli, G. Pratico, ii. p. 123, 1892- 
3.-152. Doyle, O. M. Journ. Am. M. Assoc, xxi. p. 773, 1893. — 153. Boldt, H. J. 
Med. Rec. xliv. p. 790, 1893.-154. Anscheles, J. O. Journ. akush. i jensk. boliez. 
viii. p. 734, 1893. — 155. Faidherbe, A. Arch, de tocol. p. 212, 1894. — 156. Vine- 
berg, H. N. Am. J. Obst. p. 525, 18!)5. — 156a. Butters, W. Diss. Erlaugen, 1895.— 
1566. Jacobi, M. p. Am. Journ. Obst. xxxii. p. 510, 1895. — 156c. Borland, W. A. N. 
Phila. Poly. iv. p. 485, 18.5. — 156cZ. Clapham, C. Qucu^t. Med. Journ. iv. p. 279, 1896. 

Uterus Fcetalis, Pubescens, etc. : — 157. MiIller, P. Ztschr. f. Geburtsh. u. Gyn. 
iii. p. 1.59, 1878. — 158. Budin. P. Progr. med. pp. 267 and 307, i. for 1887.-159. 
Blanc, E. Arch, de tocol. p. 3.59, 1889. — 160. Trachet. Arch, de tocol. xvii. p. 845, 1890. 

Minor Malformations and Congenital Prolapsus Uteri: — 161. Penrose, C. B. 
Univ. Med. Mag. vi. p. 185, 1893-4.-162. Mueller. Ann. di Ostet. p. 331, 1894.— 
163. Quisling, N. Norsk. Mag. for Laegevidenskaben, 4 R. iv. p. 265, 1889. — 164. 
HoRLACHER. 3/«?tc/i. msd. Wc/i?isc/ir. No. 50, 1889. — 1(55. Heil, K. Arch. f. Gynaek. 
xlviii. p. 155, 1894. — 165a. Remy, S. Arch, de tocol. xxii. p. 904, 1895. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 109 

Vagina Septa: — 166. Suppinger. Correspondenzhl. f. Schiceizer Aerzte, p. 418, 
1876. — 167. Atthil, L. Dublin Journ. Med. Sc. Ixiv. p. 165, 1877. — 168. Anway, 
J. D. Am. Journ. Obst. xi. p. 388, 1878. — 169. Cheron. Rev. nied.-chir. d. mal. d. 
femmes, iv. p. 382, 1882.-170. Galabin, A. L. Trans. Obst. Soc. London, xxiv. p. 20, 
1883. — 171. MouLTON, H. Journ. Am. Med. Assoc, x. p. 666, 1888. — 172. Schuler, 
C. Diss. Kiel, 1890. — 173. Vasten, V. A. Bolnitsch. gaz. Botkina,\. t^. 9SQ,\S'^^0.— 
174. Paschen. Centralbl.f. Gyndk. xiv. p. 16, 1890. — 175. IVLissey, G. B. Ann. Gijnxc. 
and Psediat. iv. p. 365, 1890-1.-176. Shtol, K. Otchet. Mar. ginek. otdiel, p. 47, 1891. 
— 177. GuHMAN, M. Journ. Am. Med. Assoc, xvi. p. 906, 1891. — 178. Curatulo, G. 

E. Riforma med. vii. p. 337, 1891.-179. CiAJO, A. Gazz. d. osp. xii. p. 670, 1891. 

— 180. SciALDONi, A. Glor. internaz. d. sc. med. xiii. p. 534, 1891. — 181. Halter, G. 
Wien. med. Presse, xxxiii. p. 49, 1892. — 182. Drujinin, I. N. Journ. akush. i jensk. 
boliez. vi. p. 239, 1892. — 183. Giglio, G. Riforma med. viii. p. 185, 1892.-184. 
SiCHERER, O. V. Arch.f. (r?/naeA;.xlii. p. 339, 1892. — 185. Piccoli, G. Levatrice mod. 
i.p. 58, 1892. — 186. Eberlin, A. Med. Obozr. xxxvii. p. 323, 1892.-187. Borde, L. 
Bull. d. sc. med. di Bologna, iii. p. 194, 1892. — 188. Fijchtexbuch, H. Diss, Stras- 
l)urg, 1892.-189. Umamori, S. Mino Igakkwai Hoko, No. 1, p. 86, 1893.-190. 
Fermini. Boll. d. Poliambul. dl Milano, vi. p. 53, 1893. — 191. Leuf, A. H. P. Med. 
News, Ixiii. p. 490, 1893.-192. Herrick, C. B. Med. Xeics, p. 15, July 7, 1894.— 
193. RoBB, H. Johns Hopkins Hosp. Bull. p. 50, April 1894. — 194. Semeleder, F. 
Gaceta medica {Mexico), p. 287, 1894.-195. Osmont. Arch. d. tocol. p. 139, 1894. 
— 196. Chapius. Li/on med. p. 83, 1894. — 197. Ayers, E. A. Am. Journ. Obst. p. 
104, July 1894.-198. Merttens. Centralbl. f. Gyniik. xviii. p. 1001, 1894.-199. 
Raineri, G. Ann. di Ostet. p. 473, 1894.-200. Schuhl. Ann. de gynec. p. 248, 
Oct. 1894. — 201. FoRDYCE, W. Teratologia, i. p. 61, 1894.-202. Serejinsky, G. P. 
Journ. akush. i jensk. boliez. p. 183, March 1894. — 203. Roux, G. Arch, de tocol. 
p. 59, 1895.-204. Swope, S. D. 3Ied. Neivs, p. ,391, April 6, 1895. — 204a. Chapman, 

F. B. Boston Med. and Surg. Journ. exxxiii. p. 622, 1895. 

Vagina Rudimentaria. Defectus Vaginae. Atresia Vaginae: — 205. Garde, H. C. 
Australas. Med. Gaz. ix. p. 307, 1889-90. — 206. Picque, L. Ann. d. gynec. xxxiii. p. 
124, 1890. — 207. Saehrexdt, P. Eln Beitimg zu den Mlssbildungen der Vagina und 
des Hymen. Greifswald, 1890.-208. Jacobssohx, J. Diss. Strasburg, 1890.-209. 
Jacquemard, C. Loire med. ix. p. 229, 1890. — 210. Pascale, G. Riforma med. vi. 
pt. 1, 1890.-211. Riedinger, H. Ztschr. f. Heilk. xi. p. 237, 1890.-212. Sokoloff, 

A. P. Ann. d. gyne'c. et obst. xxxiii. p. 47, 1890. — 213. Leonte. Spitahd, x, p. 611, 
1890.-214. Jepson, S. L. Tresis. 3/. 5oc. TF. nv^/^u'a, p. 759, 1890.— 215. Madden, 
T. M. Trans. Roy. Acad. Med. Ireland, viii. p. 292, 1890.-216. Frank, K. Ztschr. 
f. Geburtsh. u. Gyn. xviii. Hft. 2, 1890.-217. Asadulla, M. Indian Med. Gaz. xxvi. 
p. 9, 1891.-218. RoBB, H. Johns Hopkins Hosp. Bull. ii. p. 43, 1891. — 219. 
SwiECiCKi. Wien. med. Bl. xiv. p. 85, 1891. — 220. Loviox. Bull, et mem. soc. 
obst. et gyne'c. de Paris, p. 78, 1891. — 221. Roux. Cong, franr;. de chir. Proc.-vei^b. v. 
p. 497, Y891. — 222. Delageniere, H. Ibid. p. 346, 1891. — 223. Vagishita, T. 
Sei-i-Kwai Med. Journ. x. p. 170, 1891. — 224. Balade. Journ. de med. de Boi^deaux, 
xxi. p. 85, 1891-2.-225. Kennedy, C. M. and C. F. Univ. M. Mag. iv. p. 703, 
1891-2.— 226. La Torre, F. Bull. d. r. Accad. med. di Roma, xviii. p. 231, 1891-2.— 
227. Martin, J. N. Am. Gynxc. Journ. ii. p. 287, 1892.-228. Fulton, J. S. Am. 
Journ. Obst. xxvi. p. 331, 1892. — 229. Mangiagalli, L. Atti. d. Assoc, med. Lom- 
barda, i. p. 32, 1892.-230. Plasencia, I. Rev. de cien. med. vii. p. 169, 1892.-231. 
SwiEciCKi, H. DE. Arch, de tocol. et de gynec. xix. p. 481, 1892. — 232. Albertin. 
Province med. vii. 159, 1893. — 233. Azejia, H. Ann. de gynec. xxxix. p. 214, 1893. 

— 234. Barker, F. C. Indian Med.-Chir. Rev. i. p. 140, 1893.-235. Skene, A. J. C. 
Brooklyn Med. Journ. vii. p. 636, 1893. — 2S6. Boldt, H. J, 3Ied. R3c. xliv. p. 790, 
1893. — 237. Currier, A. F. Neio York Journ. Gynsec. and Obst. iii. p. 108G, 1893. — 238. 
RossA, E. Centralbl. f. Gyndk. xviii. p. 422, 1894. — 239. Costa, J. C. da. Med. 
News, p. 269, Sept. 9, 1894. — 240. Simon, M. Centralbl. f. Gyndk. xviii. p. 1313, 
1894.-241. Grandin, E. H. Am. Journ. Obst. xxxi. p. 249, 1895.-242. Feinberg, 

B. Centrcdbl. f. Gy7idk. xix. p. 395, 1895. — 242a. Turgard. Ann. de la Policlin. de 
Lille, iv. p. 177, 1895.-2426. Muret. Wien. klin. Rundschau, ix. p. 537, 1895.— 
242c. Hahn, H. St. Louis Med. and Surg. Journ. Ixix. p. 265, 1895. — 242d. Picque 
and ViLLAR. Progr. med. p. 284, Nov. 2, 1895. — 242e. Picque. Gaz. med. de Paris, 
9. s. ii. p. 522, 1895.-242/'. Webster, J. C. Am. Journ. Obst. xxxii. p. 544, 1895.— 
2i2g. RossA, E. Centralbl. f. Gyndk. xx. p. 145, 1896. 



"o SYSTEM OF GYNECOLOGY 



Atresia Vaginas Lateralis :— 243. Wroblewski, C. Biss. Greifswald, 1884.— 
244. Fraenkel, E. Breslau. aerztl. Ztschr. ix. p. 67, 1887. — 245. Sachs G Med 
Obozr. xxxvii. p. 130, 1892.-246. Sicherer, O. v. Arch. f. Gijnaek. xlii. p. 339* 
1892.-247. CuLLiNGWORTH, C. J. Trans. Am. Gijn. Soc. xviii. p. 434, 1893.-248. 
Sanger. Centralhl. f. Gyndk. xviii. p. 931, 1894.-249. Muret. Rev. med. de la 
Suisse rom.ande, p. 280, 1895.-250. Karra, D. A. U^iiv. izvT/estiya, xxxv. p 14<) 
1895. 

Stenosis Vaginae : — 251. Vineberg, H. N. Am. J. Obst. p. 106, July 1894.— 
252. Stone, A. K. Boston M. and S. Journ. p. 533, 1895. 

Abnormal Communications of the Vagina:— 253. Caradec. Gaz. d. Hop. No. 7, 
p. 27, 1863.-254. Rosthorn, A. v. Wlen. klin. Wchnschr. No. 10, p. 183, 1890.— 
255. Fordyce, W. Teratologia, i. p. 61, 1894. 

Double Vulva:— 256, Suppinger. Correspondenzbl. f. Schweizer Aerzte. p. 418, 
1876. — 257. Wells, B. H. Am. J. Obst. xxi. p. 1265. 1888.-258. Chiarleoni, 
G. Ann. di Ostet. e Ginecologia, xvi. p. 469, 1894. 

Atresia Vulvae Superficialis : — 259. Rauschning, P. Diss. Konigsberg, 1890.— 
260. Sanger. Centralbl. f. Gyndk. xv. p. 1022, 1891.-261. Vollmer, H. Diss. 
Marburg, 1894 (two cases). — 261a. Hue, F. Med. infant, ii. p. 467, 1895.-2616. Jan, 
M. Indian Lancet, vii. p. 123, 1896. 

Abnormal Communications of the Vulva: — 262. Elgehausen, F. Dissertation. 
Kiel, 1891. 

Anus Vulvalis:— 263. Rosthorn, A. v. Wien. klin. Wchnschr. iii. p. 183, 1890. 

— 264. Spinelli, G. Riv. din. e terap. xii. p. 173, 1890.-265. Abel, K. Arch. f. 
Gynaek. xxxviii. p. 493, 1890. — 266. Szukalski, S. Diss. Greilswald, 1890.-267. 
Puech, p. Des abouchements cong^nitaux du i^ectum a la wive et au vagin. Paris, 
1890. — 268. Frommel, R. Mdnchen. med. Wchnschr. xxxvii. p. 264, 1890. — 269. 
Himmelfarb, G. I. Arch. f. Gynaek. xlii. p. 372, 1892.-270. Parvin, T. Med. 
News, Ixi. p. 69, 1892. — 271. Rautzoin. Rev. mens. d. m.al. d". Venf. xi. p. 27, 1893.— 
272. Thompson, H. Lancet, i. for 1894, p. 403. — 273. Horrocks. Brit. Med. Journ. 
i. for 1895, p. 83. — 274. Buckmaster, A. H. Trans. Am. Gyn. Soc. xix. p. 275, 
1894.— 275. LuDWiG. Centralbl. f. Gyndk. xix. p. 349, 1895.-276. Anshelesa, U. 
Univ. izvyestiya, xxxv. p. 129, 1895.-277. Dwight, T. Am. J. Med. Sc. p. 433, 
April 1895.— 277a. Freeman, L. Med. News, Ixvii. p. 319, 1895. 

Hypospadias: — 278. Lebedeff. Arch. f. Gynaek. xvi. p. 200, 1S80. — 279. 
Strong, C. P. Trans. Am. Gyn. Soc. xvi. p. '473, 1891.-280. Frank. Wien. klin. 
Wchnschr. v. p. 413, 1892. — 280a. Bittner, C. Przeglad. chirurqiczny , i. p. 260, 
1893-4. 

Epispadias:— 281. Gottschalk, S. Dissertation. Wiirzburg, 1883. — 282. Ruther- 
ford, C. 3/ecZ. i?ec. xxxviii. p. 492, 1890. — 283. Auffret, C. Cong. fran(^. de chir. 
P roc. -ve7^b. etc. Yi. p. 233, 1S92. — 284. Dranitzy, A. A. Journ. akush. i jensk.boliez. 
p. 567, June 1894. —285. Durand, M. UExstrophie vesicale et V Epispadias. Paris, 1894. 

— 285a. Petren, K. Nordiskt. med. Arkiv, n. f. iv. No. 31, 1894. — 285&. Kuster, E. 
Berlin, klin. Wchnschr. p. 1141, 1895. 

Malformations of Labia: — 286. D'Hotman de Villters. Arch, de tocol. -K.vn. p. 
272, 1890.-287. Schtol, K. G. Journ. akush. i jemk. bolifz. iv. p. 807, 1802.— 287o. 
David, E. Journ. sc. med. de Lille, xviii. p. 372, 1895. — 287&. Shoemaker, G. E. 
Am. Journ. Obst. xxxii. p. 215, 1895. 

Atresia Hymenalis : — 288. Van der Metj. Ned^rl. Tijdsrhr. v. Verlosk. en Gynsec. 
i. p. 171, 1889.-289. Allinson, H. C. Brit. Med. Journ. i. for 1800, p. 780.-290. 
Maher, J. J. E. M'^d. Rec. xxxvii. p. 560, ISOO. — 201. Somers, L. N. U. Lancet, i. for 
1800, p. 1010. —202. Cerchrz. Clinica, i. p. 118, 1800.-203. S^sman, A. Wien. 
klin. Wchnschr. iii. p. 430, 1800.-204. Kinloch, R. A. Am. J. Obfit. xxiii. p. 836, 
1890.-205. Mayer, O. B. Trans. South Car. M. ^.s.s. p. 105, 1800.-206. Bardescu, 
N. Spitalul. X. p. 357, 1800.-207. Bevill, C. Med. Rec. xxxviii. p. 631, 1890.— 
298. Gichner, J. E. Maryland M. Journ. xxiv. p. 248, 1890-1.— 299. Wiggin, 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN lu 

F. H. Med. Rec. xxxix. p. 136, 1891.— 300. Shtol, K. Otchet. Mar. ginek. otdiel, p. 
28, 1891. — 301. Ross, J. F. W. Journ. Am. M. Ass. xvii. p. 1, 1891.-302. 
Hemenway, H. B. Am. J. Ohst. xxiv. p. 897, 1891. — 303. Strogonoff, V. V. 

Vrach, xii. p. 1058, 1891.— 304. Sochinski, P. M. Vrach, xii. p. 1139, 1891.— 
305. IVIiRONOFF, M. Journ. akiish. i jensk. boliez. vi. p. 47-4, 1892. — 306. Wheeler, 
A. Calif. Hom(£op. x. p. 206, 1892. — 307. Minard, E. J. C. N. York M. Journ. Ivi. p. 
299, 1892. —308. Vanderveer, J. R. N. York M. Journ. Ivi. p. 298, 1892.— 309. 
KoNELSKi, M. L. Vrach, xiii. p. 955, 1892.-310. Orloff, V. N. Meditslna, iv. p. 
356, 1892.-311. Rosinski. Allg. med. Centr.-Ztg. Ixi. p. 2041, 1892. — 312. Drake- 
Brockman, H. E. BHt. Med. Journ. i. for 1893, p. 1220.-313. Neugebauer, F. 
L. Medycyna, xxi. p. 429, 1893.-314. Nammack, C. E. Med. Rec. xliv. p. 81, 
1893.— 315. Thomason, H. D. /6id. p. 235, 1893. — 316. Kahn, A. Med. News, Ixiii. 
p. 380, 1893.— 317. Mudalier, A. N. K. Indian Med. Rec. p. 300, 1894.-318. 
Murphy, J. Brit. Med. Journ. \. tor \%'do, p. 65. — 318a. Rittstieg. Miinchen. med. 

Wchnschr. p. 1081, 1895. — 3186. Coromilas. Bull, et mem. soc. obst. et gynec. de 
Paris, p. 445, 1895. 

Anomalies in the Form of the Hymen: — 319. Schaeffer, O. Arch. f. Gynaek. 
xxxvii. p. 199, 1890.-320. Cordorelli Francaviglia, M. Gior. ital. d. mal. ven. 
XXX. p. 426, 1889.-321. Montane, L. Progreso med. ii. p. 445, 1890.— 322. Purs- 
low, C. E. Lancet, i. for 1895, p. 543. 

Anomalies in the Structure of the Hymen:— 323. Leisenring, P. S. Omaha 
CVinic, ii. p. 216, 1889-90. —324. Destarec, J. Thesis. Paris, 1890. — 325. Campbell, 
W. M. Edin. M. Journ. xxxvi. p. 217, 1890-1.-326. Ahlfeld, F. Ztschr. f. Gehurtsh. 
u. Gyndk. xxi. p. 160, 1891. 

Hermaphroditism: — 327. Ballantyne, J. W. Teratologia, i. p. 136, 1894.-328. 
Ibid. Te7'atologia, ii. p. 184, 1895.-329. Debout. Normandie med. v. p. 160, 1890. 

— 330. Decker, C. M. St. Louis M. and S. Journ. Iviii. p. 355, 1890.-331. Egea, R. 
Gac. med. xxv. p. 141, 1890.-332. Rosenthal, O. Wien. med. Wchnschr. xl. p. 526, 
1890.-333. Winter. Ztschr. f. Geburtsh. u. Gynak. xviii. p. 359, 1890.-334. INUnton, 
J. A. Lancet, ii. for 1890, p. 395.-335. Pozzi, S. Gaz. hebd. de med. xxvii. p. 351, 
1890.— 336. Jones, C. N. D. Med. Rec. xxxviii. p. 724, 1890. — 337. Tillatson, D. J, 
Med. and Surg. Reporter, Ixiii. p. 647, 1890. — 338. Abel, R. Dissertation. Greifs- 
wald, 1890.-339. Vaughan, G. T. New York Med. Journ. liii. p. 125, 1891. — 340. 
Polaillon. Bull. Acad, de med. Paris, xxv. p. 557, 1891. — 341. Eliot, G. T. Med. 
Rec. xxxix. p. 564, 1891.-342. Petit, P. N. Arch, d'obst. et gynec. vi. p. 297, 1891.— 
343. JouiN. Bull, et mem. soc. obst. et gynec. de Paris, p. 190, 1891. — 344. Debierke, 
Ch. L' Hermaphrodisme . Paris, 1891. — 345. Breitung, M. Dissertation. Jena, 1891. 

— 346. Roerle, F. J. Trudi Obsh. Russk. vrach v Mosk. p. 17, 1891.-347. Bishop, 
H. D. Med. Rec. xii. p. 321, 1892.-348. Worrall, R. Austi^alas. 31. Gaz. xi. p. 
107,1891-2.-349. Fehling, H. ^rc/i. /. Gji/nae^-. xlii. p. 561, 1892. — 350. Messner. 
Arch. f. path. Anat. cxxix. p. 203, 1892.-351. Nonne, M. Jahrb. d. Hamb. Staats- 
krankenanst. ii. p. 446, 1892. — 352. Guermonprez. Une erreur de seye avec ses 
conseqiiences, Lille, 1892. — 353. Frank. Prag. med. Wchnschr. xvii. p. 221, 1892. — 
354. Richer, P. N.iconog. de la Salpetriere, v. p. 385, 1892. — 355. Dailliez, G. 
Les sujets de sexe donteux. Lille et Paris, 1892. — 3.56. Lindsay, J. Glasgoio Med. Journ. 
xxxix. p. 161, 1893.-357. KuRZ, A. Deutsche med. Wchnschr. xix. p. 964, 1893.— 
358. Philippe, P. Uiiion med. du Canada, vii. p. 505, 1893. — 359. Audain, L. Ann. 
de gynec. et d'obst. xl. p. 362, 1893.-360. Bergonzoli, G. Bull, scient. No. 1, 1893. 

— 361. Pozzi, S. A Treatise on Gynecology, iii. p. 452, 1893. — 362. Brohl. Cen- 
tralbl. f. Gyndk. xviii. p. 390, 1894. — 363. Hoffmann, 0. S. Am. J. Obst. xxix. p. 
367, 1894.-364. IVL-vrtin, C. Brit. Med. Journ. i. for 1894, p. 1361. — 365. Walker, 
M. A. Neio York Med. Journ. p. 434, Oct. 1894. — 366. Zuccarelli, A. L'Anomalo, 
p. 78, 1894.-367. Willett. Trans. Path. Soc. London, xlv. p. 102, 1894.-368. 
Moostakov. Meditzina (Bidgaria), ip. 32,1894:. — 369. Schneller. Miinchen. med. 
Wchnschr. No. 33, 1894.-370. Hallopeau, H. Bull. Acad, de med. Paris, p. 425, 
1895.-371. Lagneau, G. Ibid. p. 415, 1895.-372. Meige, H. N. iconogr. de la 
Salpetriere, p. 56, 1895.-373. Pean. Bull. Acad, de med. Paris, p. 381, 1895.— 374. 
Targett, J. H. Trans. Ob.^t. Soc. London, xxxvi. p. 272, 1895.-375. Zedel, J. 
Ztschr. f. Geburtsh. u. Gyndk. xxxii. p. 230, 1895. — 375a. Lipka, A. Gaz. lekarska, 
XV. p. 980, 1895.-3756. Bittner, W. Prag. med. Wchnschr. xx. p. 491, 1895. — 375c. 



112 SYSTEM OF GYNECOLOGY 

MiNOT, F. Boston Med. and Surg. Journ. cxxxiii. p. 112, 1895. —375d. Stretton, 
J. L. Lancet, p. 917, ii. for 1895. — 375e. Neugebauer, F. Przeglad chirurgiczny , ii. 
pp. 82, 539, 1894-5.-375/. Kaplan, P. S. Diss. Berlin, 1895.-375^. Blom, R. 
Centralbl. f. Gyndk. xix. p. 685, 1895. — 375/i. Arene. Loire med. xiv. p. 187, 1895. — 
375L Hutchinson, J. Arch. Surg. vii. p. 64, 1896. 

J. W. B. 



THE ETIOLOGY OF THE DISEASES OF THE FEMALE 
GENITAL ORGANS 

The causes of the diseases of modern women are mainly attributable to 
the errors, direct or indirect, of modern life, which is yet very far from 
perfection. They may be thus classed — 

I. Abnormalities, which are produced by 

A. Hereditary congenital deficiencies of development, with 

(a) Reversion to an anterior biological type ; or 
(j8) Imperfection of adjustment, or of function, of certain 
structures ; 

B. Congenital, or subsequent arrests of development by bacillary 

inflammation or accident; and 

C. Constitutional defect, in which certain classes of cells mor- 

bidly proliferate, forming tumours. 

II. The training and effects of education. 

III. Unnatural personal habits with regard to dress, diet, repose, 
and the management of the excretions. 

IV. Absence of marriage, or late or ineffective marriage ; the last 
including absence of pregnancy by congenital defect or incapacity of the 
husband, or of the woman ; and artificial prevention of pregnancy. 

y. Excessive use and drain of the sexual organs. 

VI. Bacillary contagious diseases, such as syphilis, gonorrhoea, puerpe- 
ral septicaemia, tuberculosis, measles, scarlatina, small-pox, and diphtheria. 

VII. Accidental causes and those due to operation. 

I. Deficiencies and arrests of development, which render the gen- 
ital organs useless or lead to disease, might be attributed to inflam- 
matory interference with the circulation and nutrition due to maternal 
endometritis, or mental shock ; but these influence the whole embryo, or 
not especially its genital system. The cause is rather to be found in the 
influences of hereditary sexual feebleness, progressive in certain temper- 
aments ; or of bacillary inflammation; or of local injury in the mother. 

A. Such defective heredity is probably not generally immediate, 
but is a gradual declension, generally on the maternal side, tending by 
continuous degeneration to induce in the progeny feeble sexual forma- 
tion, frequently in the uterus. Thus the first stage may be found in a 
woman of deficient sexual appetite, having a uterus of moderate develop- 
ment, but contracted at its opening, which may be lacerated in her first con- 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 113 

finement so, perhaps, as to prevent further conception. The child, cold- 
mannered, unsympathetic and egoistic, with a feebly developed uterus and 
disgust at marital rites, becomes pregnant only by chance — it may be 
long after marriage, or after successful operation : or, with a congenitally 
contracted, though permeable upper vagina, closed hymen, or a tendency 
to the infantile pelvis with absence of sexual appetite, she becomes the 
mother of one child, who has a yet feebler unimpregnable uterus and 
atrophic ovaries, Av^ith deficient catamenial discharge, and a premature 
menopause ; or more marked abnormality may occur, and the woman be 
sterile. In the father hypospadias may exist, or some other state of de- 
ficient congenital urogenital formation. Such unions are often attribu- 
table to the inducements of money or position in marriage ; in a simpler 
state of society they would be prevented by the competitive success of 
those physically more robust. This heredity may be rectified in the chil- 
dren if the feebly sexual Avoman become pregnant by a partner of excep- 
tionally vigorous type, whereby the tendency to sexual deterioration may 
be neutralised. 

Through the ancestral series a certain portion of the original germ- 
plasma has been retained, so that the special organisation is preserved, as 
well as some particular attributes, whether physical or mental, of the par- 
ents or earlier progenitors. The influence of the highest progressive de- 
velopment attained is thus conveyed to the offspring, but with it the 
inherent capacity of recurrence to an anterior lower type. A defective 
generative vitality may thus fail to develop to the highest type of the 
immediate ancestors, and reversion to an anterior form may occur. 

As in all cases the special type of the individual is dominant, the 
impression of descent is one of degree, and the grade is in a proportion- 
ately decreasing ratio removed from that of the immediate ancestors ; 
and this appears in some special point, in Avhich the advanced cell-vitality 
has failed. This is particularly liable to occur in the generative organs, 
especially of women, which are more advanced and complicated. 

Darwin says that the most ancient progenitors of the Vertebrata, 
of which Ave are able to obtain an obscure glance, seem to have been 
a group of marine animals resembling the larvae of existing ascidians. 
These animals probably gave rise to a group of fishes, as lowly organised 
as the lancelot ; and from these the ganoids, and other fishes like the 
lepidosiren, were probably developed. From such fish a very small ad- 
vance would carry us on to the amphibians. Birds and reptiles were 
once intimately connected together, and the monotremata noAV connect 
mammals Avitli reptiles in a slight degree. In the class of mammals 
the ancient monotremata led up to the ancient marsupials, and these to the 
early progenitors of the placental mammals. Thus aa^c may ascend to the 
lemuridae, and from these the interval to the simiadse is not very wide. 
The simiadae then branched off into tAvo great stems, the ISTew World and 
Old World monkeys ; and out of the latter stem, at some remote period, 
man, the Avonder and glory of the universe, proceeded. 

Geddes and Thomson state that in all the lower vertebrata the 



114 



SYSTEM OF GYNECOLOGY 



two oviducts are distinct throughout the genital canal ; but in mammals 
the division is found only in the monotremata. In marsupials the vagina 

is single, but the uterus double ; and 
in most placentalia the upper portion 
of the uterus is double. 

Gegenbaur describes the progress 
in development in the marsupialia 
in which the two uteri are distinct, 
and two separate vaginae appear 
(Fig. 40), and says that in many ro- 
dents (lagostomus) a certain portion 
of the vagina retains its original 
double nature. The gradual bio- 
logical progress toward the human 
double uterus is shown in Figs. 41, 
42, 43, in which it is also seen that 
when the common portion of the 
uterus is elongated the cornua are 
shortened. In the simiadse, as in 
man, there is a single uterus. 

The same line of proof may be 
applied to lobate and multiple ova- 
ries, and to the various conditions 
of hermaphrodites. Thus heredi- 
tary deficiencies of development are reversions to an anterior type. 

These abnormalities, however, are more particularly attributable to 
the exact point at which the progressive development of the germinal 




40. — Female generative organs of Halmaturus 
(Gegenbaur). ov. Ovary ; od, oviduct ; u, 
uterus ; cv, vaginal canals ; cug, sinus uro- 
genitalis ; -?;«, urinary bladder ; uvt ureter. 
* Opening of the bladder. 




Fig. 41, — Two completely separated 
uteri of many Kodentia. 




Fig. 42. — The single uterus is 
continued into two separate 
cornua of the Insectivora, 
Carnivora, Cetacea, and Un- 
gulata. 



Fig. 43. —The single uterus of the 
Simise and Man. 



Various forms of the uterus (Gegenbaur). u, Uterus ; od, oviduct ; v, vagina. 



cells fails. Pure reversion to an anterior type implies a perfect develop- 
ment at the level of that ancestor; this, however, may not occur. 
Probably no defective development can take place without a deficient 
germinal cell-vitality, and such vitality may be exhausted at a point 
antecedent to that of completion of the anterior type. Thus examples 
may be found in which the condition may be described as deficient in 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 115 

contrast with that of arrest. In the former the cell vitality is low, but 
persistent ; in the latter it is worn out and atrophic. 

B. And here presents itself a special cause of germinal-cell destruc- 
tion by bacillary action, which is, through parental influence, directly 
conveyed to the embryo, and by local inflammation destroys the vitality 
and power of growth of germinal genital cells. Among such causes are 
the eruptive fevers, such as measles, scarlet fever, and small-pox, by 
which the foetus in utero may be attacked. Syphilis probably also 
exerts a determining influence on arrests of development in the progeny. 

After birth, and at any time previous to full development, these 
causes, or tuberculosis again, which specially attacks the mucous or serous 
membranes, may affect and destroy the vitality of the growing cells ; or 
an accident before birth, or subsequently, such as a blow on the abdomen 
producing an internal haemorrhage, peritoneal or otherwise, and affecting 
these parts, may arrest growth ; or a peritonitis may cause displacement 
and adhesion of the genital organs. 

Such destruction of vital force in the special germ-cells produces 
arrest of development at the stage which such development had pre- 
viously attained, and a stage of arrest restricted to the special cells 
thus affected. 

There is no necessary relation between any degree of defect or arrest 
in the development of the pelvic sexual organs and the degrees of per- 
fection of female form and of the rest of the woman. 

Congenital deficiencies and arrests of development are found in the 
ovaries. Fallopian tubes, uterus, vagina, hymen, and vulva. 

Should the development of the genital ridge be deficient or arrested 
the ovaries are so undeveloped that the external germinal epithelium has 
not ingrown for the formation of the Graafian follicles ; or is so wanting in 
completeness of structure, that these organs are unable to arrive at their 
successive monthly maturity. Whence result amenorrhoea and sterilit}^ 

If the growth of the cephalad part of the Miillerian ducts, and of the 
mesenchyma of the urogenital fold cease, the Fallopian tubes are minute 
or defective. By absence of fusion of the cephalad ends of the two 
Miillerian ducts in the genital cord, which are always tubular, the uterus 
is double ; by absence of fusion of the upper ends of the cephalad end, 
and its presence in the lower part, the uterus is bifid ; from arrest in one 
duct and development of the other, the unicorn uterus results ; after the 
normal fusion, cessation of vital growth may cause the uterus to be 
diminutive. 

When the vital force is defective or arrested in the lower half of the 
genital cord, so that fusion and absorption of the internal walls of the 
two Miillerian ducts do not occur but the remaining development con- 
tinues in each, the epithelial surfaces of each may separately continue 
their growth, meet and coalesce, closing the canals, and forming the 
proliferating cellular lamina ; the central duct-cells may subsequently 
liquefy normally, and result in two vaginae of more or less perfect 
formation. When the central cells of the ducts have failed to break 



ii6 SYSTEM OF GYNECOLOGY 

down, no vaginal canal is formed ; or the cells of one may have liquefied, 
when one vagina, perhaps of defective size, is present. Such cohesion 
of the vaginal walls may be maintained only by a thin, delicate, easily 
separated layer of the central epithelial cells, liquefaction of the central 
lamina having just failed of completion. 

The hymen, a non-muscular fold Avhich projects into the urogenital 
sinus, having on the outer surface the epithelium of the sinus and on the 
inner that of the vagina, may be imperforate by arrest of liquefaction of 
the lowest cells of the vaginal lamina, and non-formation of a canal ; or 
may have an opening into each canal of a double vagina by absence of 
fusion of the lower ends of the Miillerian ducts ; or have two openings 
into a single vagina by non-fusion of the lowest Miillerian duct-walls, 
Avith liquefaction of the central epithelial cells of each. 

Deficient formation of the clitoris and nymphse is due to defect or 
arrest of development of the genital tubercle; and of the labia majora, 
of the mesodermic prominences on either side of the genital tubercle. 

The diseases which result from defect or arrest of development in 
atresia with ovaries so well formed that the catamenia occur, depend upon 
distension of the genital canal, which is patent above the occluded 
portion, by the collection of the retained menses. Thus, with a closed 
hymen, or atresic vagina, the menses may dilate the vagina, collect in 
the uterus, and fill and distend the tubes up to the fimbriae. Should 
effusion of the menses occur through the fimbriae into the peritoneum, 
peritonitis results, of a degree of mildness or severity proportionate to 
the quantity and quality of the fluid effused if it occur before operation 
for the cure of the atresia ; it will probably be septic and virulent if it 
occur after it. 

Each segment of the double uterus may contain an impregnated 
ovum, the two perhaps of different ages ; and thus superfoetation may 
be simulated. 

The usually more feeble structure of an unicorn uterus, or of a 
segment of a bifid uterus, occupied by an impregnated ovum in progress 
of development, may cause its rupture into the abdominal cavity, and 
thus produce abdominal hsematocele and peritonitis. 

Supernumerary developments, as of nipples, are multiplications due 
to recurrence to an anterior type ; or to embryonic separation or migration 
of the special epidermal cells ; and duplication, as of ovaries, is attribu- 
table to embryonic cleavage. Duplication of the ovaries, if overlooked 
in oophorectomy for the production of the menopause, may defeat the 
object of the operation. 

The deficiency or absence of sexual appetite, and thus of engorgement 
of the erectile structures, is attributable to defective nerve formation in 
the vaginal plexus of the pelvic or inferior hypogastric plexus, and tends 
to feebler development of progeny from diminished size of the supplying 
vessels. This is the most common deficiency of development in these 
organs in civilised people : it is frequently, though not necessarily, associ- 
ated with the presence of a congenitally feeble uterus ; and also, but less 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 117 

commonl}', with, a uterus which, is normal, except that there is deficiency 
in size of the external opening : all these things tend towards sterility or 
limitation of propagation, either by direct prevention of the entrance 
of the sperm, or by that frequent refusal of intercourse, and subsequent 
avoidance by the husband, which is commonly known as incompatibility 
of temper. 

The uterus, with normal length of cavity but of feeble development, 
may be deficient in size, strength, and weight ; and may have a feeble cer- 
vico-corporeal junction, so that the body, unable to maintain its normally 
slightly anterior curvature, may fall by the pressure of the intestines above 
it into the horizontal position ; the cervix, on the other hand, readily 
yielding to the anterior force of a distended rectum, looks forwards 
and downwards ; thus the anteflexion of the feebly developed uterus 
ensues. With this in the marked condition, is coincident deficiency in 
size of the opening, so that obstruction — by the angle of the anteflexion 
— to the passage of the secretions increases the tendency to their delay 
within the cavity of the uterine body : the latter is thereby the more 
strongly depressed into the horizontal position, and dysmenorrhoea and 
sterility result. 

The cervicitis occasionally found in connection with the feeble ante- 
flexed uterus is thus produced. The secretions collect within the cavity 
of the body by the obstruction at the inner os, which is usually caused 
by the angle of flexion ; distension then induces muscular contraction, 
and this forces the menstrual blood past the angle into the cervical canal ; 
but as the external opening is congenitally minute, escape is again hin- 
dered, and the cervical cavity is thus also dilated : the quantity of the 
corporeal secretion increases, muscular contraction follows, and escape 
is effected; but the cervical membrane at the external os has been 
depressed, irritated, inflamed, thickened, everted, and become granular, 
and this, however slight it may be, narrows the opening yet farther. The 
cervical tubulo-racemose glands have been compressed by the pressure 
of the secretions, and their mucus is thus retained within their tubules ; 
they become irritated and inflamed, and secrete an increased quantity 
of mucus, which becomes abnormally cohesive and ropy. This mucus 
presently extends from the columnar secreting cells in the glands, occupies 
their canals, unites with the secretion of adjacent glands, fills the cervix, 
projects through the external os, and by its constant pressure gradually 
dilates the external os. Thus at the time of examination the cervix may 
present downwards and forwards, the external opening may be of normal 
size and occupied by cervical mucus, the cervical canal may be dilated, 
the inner os, perhaps lying to the side of the central line from unequal 
lateral hyperplasia, may be difficult to find : the body of the uterus 
may be horizontal, forming an acute angle of anteflexion with the cervix, 
and the whole uterus may be of feeble structural development, although 
it may measure 2\ inches in its canal. The dysmenorrhoea may have 
ceased or not, according to the degree of stenosis, by bending or hyper- 
plasia of the inner os ; but sterility remains. 



ii8 SYSTEM OF GYNECOLOGY 

The dysmenorrhoea which occurs a clay or so before the flow is due to 
engorged vessels in the endometrium around the utricular glands ana on 
. the mucous membrane, of which the columnar epithelial cells and under- 
lying connective-tissue-matrix are proliferated; so that the general struct- 
ure is thickened, and presses on the irritable nerves derived from the 
pelvic plexus — the pain being referred to the promontory of the sacrum, 
and ceasing when escape of blood from the vessels relieves their tension. 
But the dysmenorrhoea occurring synchronously with the flow, in conse- 
quence of rapid uterine distension and contraction necessary to overcome 
obstruction, is felt at the lower abdomen in the uterus itself ; and this 
ceases when the stenosis has been overcome and continuous escape estab- 
lished. 

The normal uterus may be deficient only in the form of the conical 
cervix, or in the size of the external opening — due, in the former case, 
to deficient cervical structural development, and, in both, as to size of 
the opening, to deficiency of development of the lower part of the cervical 
canal, or to undue contraction of the lower circular muscular fibres. 
The body may be weighed down by temporary catamenial retention or 
excessive abdominal pressure, and thus be horizontal, occasioning some 
stenosis by bending at the upper cervix : generally speaking, dysmenor- 
rhoea and sterility will ensue. 

Again, the uterus may be well and strongly developed in all other 
respects, but the cervical mucous membrane at the external orifice, which 
often extends on to the vaginal face of the cervix, may extend within the 
cervical cavity. The simple early embryonic epithelium, lining the cavity 
of the genital canal during development, changes its character in the lower 
third, which is the vaginal portion, becoming there a stratified pavement 
epithelium, which passes very gradually into the cylindrical epithelium 
of the upper, uterine portion. The change progresses upward, and, as it 
advances, the demarcation between the two kinds of epithelium becomes 
sharper, and at the eighth month of utero-gestation is abrupt at the 
junction of the uterine with the vaginal canal ; the vaginal stratified 
epithelium often extends a short distance inside the os uteri (Minot), but, 
on the other hand, frequently fails to reach it. This congenital, ap- 
X3arently granular os is attributable to one or other of the following 
conditions : — 

(1) That the vaginal stratified epithelium is deficient in extent of 
growth up to the lower border of the cervical canal, and thus the cylin- 
drical epithelium projects into the vagina, and is exposed ; or 

(2) That the lower cervical glands and cylindrical epithelium, being 
developed beyond the enclosed lower cervical opening, remain exposed, 
because the circular muscular fibres, which become distinct about the close 
of the fifth month, do not subsequently contract at the lower border of 
the cervical canal sufficiently to include them within the canal. 

The effect of this exposure of the glandular structures at the external 
opening of the cervix to the influences of the acid vaginal secretions, and 
to friction against the vagina on movement, intensified by fixation due to 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 119 

abnormal abdominal pressure, is the production of an excessive supply 
of blood, which causes congestion and inflammation of the glands and 
increased secretion of their strongly cohesive mucus, which plugs the 
canal : the uterine vessels thus becoming enlarged, a varicose state may 
be induced, and the whole uterus become congested, so that general 
endometritis ensues. Also, the connective tissue at the face of the cervix 
becomes hyperplastic, the lips are compressed, and thereby the secretions, 
which are usually plentiful, lind difficulty in escape : the uterus becomes 
irritated by distension, so that endometritis is increased, and evolution- 
ary disease of the tubes, peritoneum, and ovaries, and (under the con- 
current influence of excessive abdominal pressure) anteflexion or retro- 
version ensue : hence result virginal menorrhagia and dysmenorrhoea, and 
sterility on marriage. 

Vigorous sexual development is specially noticeable in families and 
races which bear many children, among which may be particularly men- 
tioned nations inhabiting or derived from the warmer climates. Of these, 
Jewesses are liable to the congenital granular os of strong formation, 
and to the small external opening. These conditions are compatible 
with coincidence of such a deficiency of development as permits the 
closure, or almost complete closure, of the genital canal by the hymen. 

The deficient structure of the cervix of the feeble antefiexed uterus, 
through the small opening of which the sperm has by chance passed 
and impregnated the ovum, is, even on the hypernutrition of pregnancy, 
ill adapted to bear the strain of dilatation in labour. The pressure of 
the membranes does not act to advantage on the minute opening, so 
that the cervix may be stretched out and rigid, and the wedge of the 
membranes unable to engage. Thus the circular fibres are irritated, are 
in a state of tonic spasm, and act at advantage ; but the longitudinal 
fibres, being lengthened by the downward pressure of the rounded 
membranes, act at disadvantage. Should the expulsive force be suffi- 
cient and the spasm continue, laceration of the cervix may be very ex- 
tensive ; or the lower segment of the uterus may rupture or be torn off. 

On dilatation, the circular muscular fibres are deficient in strength 
and the cervix in structural breadth; thus laceration is frequent. 

In the strong uterus with a deficiently developed os, there is a 
liability to laceration from the comparative non-dilatability of the 
small opening. Should bilateral laceration occur, lateral eversion takes 
place from contraction of the two halves of the torn circular muscular 
fibres ; and horizontal eversion of the cervical face from contraction 
of the longitudinal muscular fibres, which are no longer restrained by 
the circular. But the edges of the wound are healthy, and the epithe- 
lium may readily spread thence on to the raw surfaces, unless pre- 
vented by subsequent vaginal friction from undue abdominal pressure. 

In unilateral laceration eversion is apt to be slight; the circular 
fibres are ruptured at one side only, and the other side remains of 
strong structure, sufficient to counteract the longitudinal contraction 
and prevent eversion of the face of the cervix ; the circular fibres, on 



I20 SYSTEM OF GYNECOLOGY 

the other hand, having only one line of laceration, retract at slight 
advantage. Thus the eversion is only unilateral, and of small extent. 

These actions, necessarily less marked in the feeble cervix because 
it is small in every direction, are accentuated in the large, strongly 
developed cervix. 

To pressure in labour, long continued by the difficulty of dilatation 
of the small opening or other conditions of obstruction, may be due, by 
stasis of blood, the necrosis of tissue which, on separation after a few days, 
permits the passage of the excretions of the adjacent bladder or rectum 
affected, as well as of the slough, through the genital canal. Thereby 
a sinus is formed, called vesico-vaginal, recto-vaginal, or other fistula. 

In pregnancy in the strong uterus, with the virginal everted granular 
face and hyperplasia, from the large size of the opening dilatation pro- 
ceeds readily up to a certain point, when the head commences to pass. 
But the connective hyperplasia is ill adapted to excessive dilatation ; 
and, when the great strain of expulsion of the head through the cervix 
is put upon it by the well-developed uterus, extensive laceration of the 
cervix usually results. The subsequent granular face and eversion are 
apt to be great ; for the previously granular hyperplastic membrane is 
not readily susceptible to epithelial growth, and the raw and deeper 
newly lacerated central faces are thus far removed, except at the sides, 
from vaginal epithelium. Moreover, the longitudinal cervical muscular 
fibres act at advantage, so that the lower edges of the faces are drawn 
upwards and outwards, and everted. This action is not restrained by 
the circular fibres, which are torn across ; hence the lateral edges of 
the cervical wound are drawn outwards, and still more everted. 

In subsequent confinements the extent of laceration is generally 
increased, since the angles of previous laceration are healed by cicatri- 
cial connective tissue, which is ill adapted for dilatation ; or they may 
also be hyperplastic, which is still less so, being softer and less strongly 
formed and resistant. 

When the first stage of labour has been unduly prolonged by delay 
in dilatation of the strong cervix with deficient formation of the os, the 
uterus is liable to become irritable, and to be aroused to excessive vigour 
of contraction, in which, owing to the pain and general excitability of the 
woman, the accessory muscles participate; thus labour is precipitated and 
the head may be forced down with violence on the perineum. Should 
the power be much greater than the resistance, the head may burst 
through the perineum before the muscular structures have had time to 
dilate ; whence perineal laceration, which is extensive in proportion to 
the want of due relation of these forces. Or the vagina and perineum, 
rigid in accordance with deficient sexual appetite and development, 
may not have sufficiently softened in pregnancy, and may not readily 
dilate, so that in the passage of the child perineal laceration occurs. 

From deficiency of dilatation from the foregoing causes it may be 
necessary that assistance by the forceps be given to the passage of the 
child. The state of the parts, whether of the cervix or perineum, ren- 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 121 

ders a gradual advance most appropriate ; while the condition and feel- 
ings of the woman, weary and in excruciating pain, seem to indicate the 
desirability of speedy delivery. Under such circumstances the forceps 
are very often used without an anaesthetic, and laceration is frequently 
thus effected ; even if the head have not passed through the cervix the 
forceps may be made to draw it down quickly, after which the increased 
pain by pressure on the perineum as yet unstretched induces the at- 
tendant to hurry, and a few minutes only may be given to dilatation 
in place of the two hours which nature would have employed. But if 
chloroform be given these influences are lessened, dilatation may be 
quietly effected, and laceration prevented or limited. 

If the fresh, raw surfaces at the cervix or perineum, lacerated deeply 
into the broad ligament or recto-vaginal connective tissue respectively, 
absorb septic germs, a pelvic cellulitis results commensurate with the 
virulence of the sepsis. If of the most violent type, there is a general 
suppurative oedema of the connective tissue and suppurative phlebitis, 
and death probably ensues. Or, the microbic attack being less virulent, 
a suppurative thrombus may be impacted in a vein, guarded toward the 
heart by a sufficiently healthy adherent clot, and the increasing pus 
may burst through the venous wall, infecting the adjacent connective 
tissue and presenting in the direction of least resistance : if the mi- 
crobes be detained in the lymphatic glands a similarly localised pelvic 
suppuration may occur. A local necrosis of connective tissue at the 
site of laceration may escape by the genital canal, or a benign inflam- 
mation terminate in resolution. 

The morbid influence of the micrococci is effective only so long as 
the power of the septic micro-organisms is greater than that of the 
phagocytes and leucocytes, so that the former force a passage into, and 
are carried by the lympathic and blood vessels into the general system ; 
if the latter presently overpower and destroy the micrococci, the healing 
process forms granulations guarded by an army of victorious cells, and 
parasites can no longer gain admission, though they may create a local 
superficial suppuration [vide article on Inflammation]. 

It is not rare that the angle of laceration in the cervix has been so 
high that the tension of the growth of the ovum in succeeding pregnan- 
cies causes such irritation as exaggerates the normal uterine contrac- 
tions, and miscarriage or premature labour results. 

The appropriation of the absorbing, healing, and nutritive action of 
the lymphatic and blood vessels in such inflammation of the lacerated 
cervix, at the expense of that which the removal and renewal of the 
parts requires, usually results in subinvolution of the ligaments, and of 
the muscular, connective, venous, and nerve tissues of the pelvis and gen- 
eral system in proportion to the strength of the inflammation, its extent, 
and the degree of its subsequent continuance and drain. Should lacer- 
ation of the perineum, as well as of the cervix, have occurred, subinvolu- 
tion of all the genital structures generally results ; if only of the one or 
the other, then of the parts specially allied to the nutrition of that one. 



122 SYSTEM OF GYNECOLOGY 

The misplacements which may arise in connection with subinvolu- 
tion are described in section 3. 

The subsequent occurrence of sterility or pregnancy is dependent on 
the degree to which the cervical circular muscular fibres and external 
cervico-vaginal wall are lacerated, effecting more or less e version up to 
the level of the uninjured canal ; should the opening in such complete 
lateral laceration be narrowed by the pressure of everted cervical mucous 
membrane and ensuing hyperplasia, whereby the normal trumpet-shaped 
opening is lost, the sperm cannot enter, and sterility results ; or a cer- 
vicitis and endometritis may result from vaginal friction, and mucous 
secretion plug or fill the uterine tube. But if the laceration do not 
extend through the outer wall of the vaginal cervix, the canal may be 
of an enlarged trumpet-shape, and the sperm enter with unusual readi- 
ness ; or the end of the penis may penetrate such a canal, and directly 
inject the sperm into it, effecting rapidly recurring pregnancies. 

The state of constant excessive proliferation of cells of low type by 
the granular hyperplastic lacerated cervix is most favourable to the de- 
velopment of cancer, which is further discussed in section C, on consti- 
tutional causes. 

Endometritis, with or without displacement and subinvolution in the 
parous, having been induced by one or other of the causes previously 
mentioned, or by the action of special microbes, as of gonorrhoea or 
puerperal septicaemia, some thickening toward the uterine end of the 
Fallopian tube, which is only of the size of a fine bristle, takes place 
by extension of the endometrial inflammation to the tubal mucous mem- 
brane and the consequent obstruction frequently increased by stenosis 
of the cervical canal, which mechanically hinders or prevents escape of 
the uterine and tubal secretions. 

The secretions, accumulating in the tube, overflow through the fimbria 
into the abdominal cavity, whereby an irritation or inflammation of the 
peritoneum is caused proportionate to the quantity and quality of the 
fluid effused ; peritonitis being always due to the entrance of irritating 
matter — gaseous, fluid, or solid — into the abdominal cavity directly, or 
by transudation under great inflammatory distension. In the effusion of 
a bland fluid — as of a healthy tubpJ mucus, mild ovarian follicular fluid, 
small quantities of blood or healthy urine — the irritation may not 
amount to more than an excitation of the peritoneal endothelial cells for 
the purpose of its absorption, and the fimbria may remain free and unin- 
jured. On the relief of an existent cervical cause of endometritis, such as 
granular eversion, virginal or from laceration, the tubal stenosis may 
cease ; and the tube may again become normal. Should the effusion be 
more irritating and septic, fibrin is exuded by inflammatory action of 
the peritoneum ; thickening of adjacent structures, or adhesion by con- 
nective tissue organisation of the exuded fibrin occurs, and the fimbria 
of the tube becomes attached and closed ; the tubal secretions, collecting 
in the more dilatable mid-part of the tube, then distend it, and a pyo- 
salpinx is formed. Under pressure the uterine end may yield and the 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 123 

pus escape through the genital canal : if this do not occur and the bacterial 
virus be moderate in power and become attenuated, the secretion may 
not increase in quantity ; pus-cells may undergo fatty degeneration and 
absorption, and a more or less stationary hydrosalpinx presently result : 
or, again, if the healing process be less complete, caseous pus may persist. 
But if the bacteria be virulent in quantity or quality pus continues to 
collect, and, by increasing pressure, a gradual thinning of the tubal wall 
at the site of least resistance takes place. As the inner coats of the 
tube break down, its peritoneal coat yields, and presently a minute per- 
foration permits a slight effusion into the peritoneal cavity. Thereupon 
an exudation of fibrin occurs about the site of such rupture, and the 
peritoneal surfaces of the tube and the adjacent viscus (commonly 
intestine) cohere. As the tubal distension continues to increase, an 
opening through the united peritoneal layers into the viscus occurs, and 
the pus escapes from the tube. Through this opening, or by penetration 
through the adherent, inflamed, distended, thin, intervening structures, 
bacilli from the viscus, such as the bacillus pyogenes foetidus from the 
intestine, may enter the tube and render the pus foetid. Sudden pressure 
may cause rupture directly into the peritoneum and a virulent peritonitis. 
In labour the pressure of the foetal head may rupture the pyosalpinx 
into the broad ligament, and thus extensive suppurative connective tissue 
may spread in the direction of least resistance, the vigour of the extension 
being dependent on the character of the bacillary cause of the tubal 
suppuration : it is specially virulent in gonorrhosal infection. 

Should the effusion from the fimbria be of a virulent character, such as 
septic pus, there may be a preliminary slight oozing which, while creating 
a severe inflammation of the adjacent peritoneum at the site, yet permits 
the exudation of organisable fibrin at a slight distance, so that the fimbria 
becomes encapsuled, and perhaps adherent; but a septic abscess may thus 
be originated by this effused pus between the fimbria and the adherent 
viscus ; whence arises a tubo-peritoneal abscess, which may be tubo- 
ovarian. If there be more extensive peritonitis with distant organised 
adhesions, peritoneal abscesses, perhaps saprous by intestinal bacterial 
transudation, may be formed ; and the omentum, by lymphatic absorption, 
may be studded with abscesses and adherent to the abdominal wall. But 
if the effusion be large or continuous — as of such septic pus, when organis- 
ing fibrin has not been exuded, or has not attached and occluded the 
fimbria on account of the virulence of the effused matter — the peritonitis 
is general and virulent, and the exudation sero-purulent with occasional 
coheriug fibrin-flakes. 

The peritonitic exuding organising fibrin may attach adjacent abdom- 
inal or pelvic surfaces, as those of the uterus, tubes, ovaries, intestines, 
vermiform appendix, omentum, or abdominal or pelvic wall; or form bands 
like floss-silk, violin strings, or tapeworm. The intestines, during the 
period of acute inflammation, are comparatively stationary, except for 
gaseous distension ; but during the period of convalescence they undergo 
considerable alteration in position by vermiform action. The connective 



124 SYSTEM OF GYNECOLOGY 

tissue adhesions become stretched by these movements of the intestines; 
and, later, may constrict them, and produce various degrees of obstruction 
to the passage of flatus or faeces, and to the circulation of the blood. 
Between extensive organised fibrinous adhesions serous sacs may be 
formed, either by the presence of attenuated bacilli in adjacent peritoneal 
surfaces and irritation of them, or by transudation of serum from veins 
constricted by bands or adhesions. This latter condition is seen when 
the abdomen is opened for the relief of intestinal strangulation caused 
by such a band. 

By the organisation of the exuded fibrin into connective tissue the 
tubes may be bound down at the fimbriae, or more extensively ; or the 
two fimbriae may cohere posteriorly. Thus they are in future, perhaps, 
unable to apply themselves to the site of the mature Graafian follicle ; or 
one may be thus adherent, and the other, being free, may apply its 
fimbria to the other ovary on ovarian maturation. 

The irritation produced by effusion from the fimbria of the tube causes 
a thickening of the tunic of the ovary by its inflammatory cell multiplica- 
tion and condensation ; if the peritonitis be more severe, the surface may 
be coated with exuded organised fibrin, which may form into bands, or 
be densely adherent to adjacent peritoneum. When the ripe Graafian 
follicle has advanced from within the ovary to this thickened and 
condensed surface layer, its further progress is thereby impeded ; the 
liquor folliculi may increase in quantity beyond the normal, and a 
haemorrhage take place into the cavity and so effect its rupture. The 
ovarian tunic may yield under this increased tension, when a fimbria may 
by its previous affections be unable to apply itself, and its abnormal 
contents may thus fall into the abdominal cavity. By the stress of 
such a follicle on the ovary an undue pressure on the ovarian stroma may 
create pain, and by the escape of the contents into the peritoneum a 
peritonitis be caused. The opening may be quite minute, or door-like 
and valvular by contact with the adjacent peritoneum, so that the fluid 
oozes out gradually ; and, the irritation causing peritonitis being thus con- 
tinuous, the temperature may remain high, though the inflammation be 
really confined to the locality of the effusion. Degrees of pyrexia in peri- 
tonitis seem often to be dependent on the degrees of mildness or virulence 
of the effusion, and on the excess of absorption over exudation. It is 
often high when the cause is mild, and absorption by the lymphatics into 
the system active ; normal, when the effusion is virulent and peritonitic 
exudation dominant ; and low from debility and shock, if a large quantity 
of blood be poured into the peritoneum by rupture of vessels. 

Such ruptures of different cysts may be consecutive, producing recur- 
rent peritonitis; and should blood be present in the follicles, the irritation 
is the greater. Frequently rupture is not effected, and a follicular cyst 
remains which may be filled with blood ; this is possibly more generally 
the case when the maturity of the follicle has been coincident with men- 
struation or sexual union. Such follicular cysts may attain to the size of 
a walnut, or occasionally larger than that ; and, finally, as the gradual 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 125 



increase of fluid thins and ruptures the walls, they may empty themselves 
into the peritoneum and produce peritonitis. 

By the continuance of pressure of these cysts the ovarian stroma is 
permanently compressed and atrophied; and the ovary may be com- 
posed of little more than such sacs. This fluid may after a time be 
absorbed, when the ovary by contraction of the sac-walls will appear 
to be cirrhotic; but the outer walls of the cysts remain mainly as 
connective tissue condensations. 

If in the earliest period of septic infection of the fimbria, which is 
usually puerperal, gonorrhoeal, or tuberculous, its effusion have had time to 
effect a peritoneal exudation causing cohesion of the fimbria to the ovary, 
a free escape into the peritoneum may have been prevented, and the 
fimbria may have become adherent to a subsequently ripening Graafian 
follicle, which may rupture into the lumen of the tube : the septic matter 
may thus enter the cavity of the follicle, and lead to a septic abscess of 
the ovary ; or bacteria may penetrate the thinned wall of the follicular 
cyst, which is inflamed by contact. The further progress of abscess of the 
ovary is described under section 6, as its causation is always bacillary. 

When tubal disease of a moderate degree is in progress of recovery, 
extra-uterine foetation may occur. The disease may have arisen from 
endometritis, however caused ; but specially from the virginal granular 
cervix or from a lacerated cervix, which may have been cured by opera- 
tion ; or it may have had a gonorrhoeal origin, with attenuation of the 
bacteria under conditions of free uterine drainage. There has been 
stenosis of the uterine end of the tube, and perhaps some mild peritonitis 
from tubal distal effusion : in process of recovery this stenosis has been 
mitigated, but not completely removed, and the semen has been able to 
enter the tube and impregnate the ovum. If the outer part of the tube 
be sufficiently patent, the ovum may be able to advance to the portion 
Avithin the uterine wall, where it may be stopped by the congestion of 
fecundation external to the site of the stenosis, and there develop as a 
tubo-uterine foetation. Should the site of the stenosis be more external 
the gestation is tubal. 

In rupture of a tubal gestation more or less of the contents of the 
ovum, with blood from the torn chorionic villi, may be discharged through 
the fimbria and form tubal abortion ; or through the lateral wall into the 
abdominal cavity, and produce peritoneal haematocele and peritonitis, 
of which the degree and progress will vary with the quantity of blood 
lost in relation to the bacilli of the original salpingitis, which probably 
escape with it from the tube external to the envelope of the ovum, 
and the subsequent necrosis of the ovum : or again into the broad liga- 
ment, forming a hsematocele in its connective tissue, the blood forcing 
its way in the direction of least resistance, and perhaps suppurating 
under the influence of bacilli introduced from the tube, which may 
throughout have remained mildly septic from the original causation 
of its disease. 

If the quantity of blood lost by such rupture be so slight that the 



126 SYSTEM OF GYNECOLOGY 

ovum survives, the subsequent condition is that of a compound abdomi- 
nal pregnancy, with such relations of the placenta as are determined 
by its situation, either below the foetus toward the floor of the pelvis 
or above it in the abdominal cavity. 

The pressure of the enlarged tube or ovary may push the uterus 
over to the opposite side, effecting latero-version, from which there 
may be recovery on subsidence of the tumour. Or a peritonitic exuda- 
tion from tubal or ovarian effusion, or a hsematocele may similarly 
displace the uterus to the opposite side; but, on absorption and 
organisation, the uterine body may be drawn over by the condensed 
exudation and permanently retained on the affected side. 

C. The hereditary constitutional defects, in which certain classes 
of cells morbidly proliferate, are dermoid tumour, parovarian cystoma, 
cystoma of Gartner's tubes, ovarian cystoma, papilloma, myoma, sar- 
coma, and cancer. 

By " Constitutional " is not meant that the disease will certainly or 
probably occur because of heredity, but that there is a constitutional 
capacity for such cell proliferations, should the parts be placed under 
suitable exciting causes. Thus, as to the development of cancer from 
the continuous irritation of a granular cervix, the latter may in some 
cases persist to the end of a long life and remain benign ; in others, 
where there is a constitutional capacity of such cell degeneration, it 
readily becomes malignant. 

The etiology of the dermoid tumour is attributable to the origin and 
mode of development of the ovary. From the mesothelial division of 
the mesoderm are formed the ovary and striated muscle; from the 
mesenchyma, which is the other division of the mesoderm, come the 
connective tissue, the heart and blood-vessels, lymphatics, smooth 
muscle, fat cells, and the skeleton. The dermal bones, which are those 
of the head and face, and are most frequent in dermoid cysts, are formed 
by direct ossification of connective tissue; they are homologous with 
the plates formed by the fusion of epidermal teeth, or of the so-called 
placoid scales which are true teeth developed in the skin and supported 
by a base of bone : of them there is the stage of scattered independent 
dermal teeth (dermoid scales) ; teeth-bearing plates formed by the fusion 
of the expanded bases of adjacent teeth (exo-skeleton) ; and membrane- 
bones developing without the appearance of teeth. (Minot.) 

The mesothelial layer of the mesoderm is closely connected with 
the ectoderm ; the mesenchyma with the entoderm. 

From the ectoderm are developed epidermis and epidermal structures, 
such as hairs, nails, glands (sebaceous, sudorific, salivary, and mammary, 
the mammary being a hyper-development of the sebaceous), the eye, and 
the mouth-cavity with the teeth ; all of which structures are occasionally 
found in the dermoid cyst. Thus in the formation of the dermoid ovum 
some mesenchymatous and ectodermal cells have by migration been 
incorporated with the mesothelial, and, continuing a constitutional 
abnormal growth, originate and produce the contents. 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 127 

A projecting dermal bone may perforate the sac wall and produce 
peritonitis, whereby the adjacent structures cohere so that bones and 
other contents may escape through the bladder or intestine ; but the 
sac probably inflames on the admission of bacteria. 

After the period of vital activity and growth of the contents of the 
tumour, growth may cease by deficiency of nutrition, caused by bending 
of its vessels from the pressure of the tumour, or by the diminished size 
of the blood-vessels after the menopause ; retrogression may then set in 
and pass through a stage of fatty degeneration, absorption, and calcare- 
ous transformation of the sac wall and its contents which may thus 
become atheromatous or calcareous. Crowding, by excessive local cell 
proliferation occluding small vessels, may produce necrosis of some part, 
as of a sebaceous gland, whereby suppuration within the sac may be 
induced ; the pus may become foetid by transudation through inflamed 
distended adherent sac-intestinal walls, or by the direct admission of 
putrefactive germs from adjacent adherent perforated intestine, or by 
operative septic puncture. Or suppuration may proceed from the irrita- 
tion, inflammation, rupture, and necrosis from excessive proliferation of 
a papilloma within the dermoid, either on the inner wall of the sac or 
on dermal plates : or by further cell degeneration cancer may ensue. 

The parovarian cyst is caused by an embryonic deficiency of absorp- 
tion, and a subsequent hypertrophic glandular secreting development of 
the granular cylindrical lining cells, which normally remain quiescent in 
the sexual part of the female rudimentary Wolffian ducts situated in the 
connective tissue of the broad ligaments. In the early embryonic state 
the future male is indistinguishable from the future female. In the 
male the developed epididymis is the analogue of the atrophied epooph- 
oron or parovarium of the female. The epididymis is lined with colum- 
nar epithelium ; and a continuation of this layer with secreting power, 
and deficiency of resorption or atrophy in relation to hypernutrition, 
originates the parovarian cystoma. It is probably a continuance of or a 
reversion to an embryonic or local hermaphroditic type. In its enlarge- 
ment it parts the walls of the broad ligament, and spreads out upon its 
surface the Fallopian tube and fimbria, and later the ovary; it may 
extend deeply into the connective tissue layer of the pelvis, or on the 
uterus. As the cells lining the sac have but slight power of proliferation, 
probably from defective nutrition of a structure normally in arrest of 
development, the sac Avail is very thin ; and there is no ingrowth, for this 
is not the mode of its analogue, the epididymis, nor of antecedent phases : 
thus the cyst is unilocular, unless by cystic development of more tubules 
of the parovarium ; and veins do not become varicose and rupture inter- 
nally, unless by rotation of the pedicle, or their kinking under pressure 
of the tumour. For the same reason secondary growths, such as papil- 
loma, which require local hypernutrition, are rare. 

A cystic tumour situated laterally in the vagina may have its 
origin in a similar state of one of Gartner's tubes, which are the lower 
parts of the atrophic Wolffian ducts, are the analogue of the male 



128 SYSTEM OF GYNyECOLOGY 

adult spermiduct and vesiculse seminales, and run through the genital 
cord. 

As to the etiology of ovarian cystoma, in the development of the 
ovary portions of its external germinal columnar epithelium grow in- 
wards, and some of these cells become ova ; while deeper multiplied cells 
of the same description form the membrana granulosa of the Graafian 
follicles. The normal function of these cells is to conduce to the nutri- 
tion and further development of the ovum, which has the highest power 
of progressive development in the body. But it occasionally happens 
that the tendency to continuous proliferation of the cells of this layer is 
greater than the subserviency to perfection of growth of the ovum, and 
their multiplication is in excess. At the same time the inner cells 
rupture and pour their secretion internally ; by such continuous process 
an ovarian cystoma is formed, which persistently enlarges. It is a 
constitutional degeneration into a glandular secreting structure. 

As the cells of the germinal epithelium do not all arrive at the produc- 
tion of the complete Graafian follicle, but there are many less well- 
nourished primitive ova embedded in the stroma, it is possible that, while 
the better-nourished cells of the membrana granulosa are most apt to 
undergo this degeneration and the cystoma to be formed originally in a 
Graafian follicle, those in the stroma may also proliferate in a similar 
manner under the influence of the existing constitutional tendency. 

In this growth, morbid in man, may be seen a strong analogy to the 
development of the ova and the yolk-food in some lower creatures. In 
them from the inner wall of the germinal plasma grow cells, usually 
columnar in character, which form (a) ova, or (&) germinal cell-nests ; from 
among these one or more ova may be produced, Avhile the rest of the cells 
serve as yolk-food and disintegrate. The number of ova in some creatures 
— as nine millions in the cod, three to six millions in the conger (7, 9), 
and seventy thousand in the woman — is frequently prodigious. The sac 
membrane may bud off internally, and form laminae and branches for 
further cell proliferation on their walls, and subdivision of the ovarian sac. 
These partitions may break down to permit extrusion of the ripe ova. 
Some creatures, as for instance the conger, breed only once, and die by 
the enormous distension of the body by accumulation of ova, which, in 
captivity, are incapable of escape. In ovarian cystoma the multiplication 
of cells thus closely simulates and is analogous to similar proliferation in 
lower creatures, either as primitive ova-cells, or as germinal cell-nests, 
undergoing progressive degeneration ; and may be regarded as a morbid 
hypertrophic germ-plasma cell proliferation reversionary to an anterior 
type. Although children have been born with this disease, and occasional 
instances are found in the early years of life, when the condition may 
be regarded as one of defective development, it is most commonly 
found to commence during the years of strong generative ovic vitality ; 
and many patients, nearly a third, are single. It is thus probable that 
ovarian cystoma is a degenerative reversionary proliferation of the ger- 
minal ovic epithelium (akin to that of the unstriped muscular and connec- 



ETIOLOGY OF DISEASES OF FEMALE GENLTAL ORGANS 129 

tive cells occurring in myoma), in relation to absence or deficiency of their 
normal employment, namely, the production of the next generation. 

The degeneration being thus of a type which affects the develop- 
ment of all the cells of this class, the disease does not attack one fol- 
licle only, but is common to all ; not necessarily at the commencement, 
but subsequently. Hence a cystoma, on its attainment of some size, is 
almost always multilocular 5 one sac may, however, by appropriation of 
the most nutrition, attain to the greatest size. 

By ingrowths of the lining columnar cells a cyst may be divided, 
and by such repetitions it becomes additionally multilocular. By the 
thinning and rupture, or the necrosis of a partition by excessive press- 
ure of the fluid on one or both sides respectively, two cysts may become 
one. By varicosity of veins induced by the pressure, which is fre- 
quently at the junction of the tumour with the pedicle, or by pressure 
of adjacent rapidly growing cysts on a vein, the rupture of a vein may 
occur ; and one or more cysts in a multilocular tumour may be filled with 
blood. By similar partial pressure on the arteries and veins reducing 
nutrition, fatty, purulent, or calcareous degeneration of the lining cells 
and thus of the contents results, whether of one or more of the cysts. 

By some kind of changing pressure, such as manipulation, descent 
of faeces, vigorous alteration of position, or tension of or pressure on 
the tumour as in lying, or by the growth of the pregnant uterus, or 
in parturition, or on removal of pressure as after parturition, or on 
change in form of the tumour, as by the emptying of a large cyst 
in a multilocular tumour by tapping, rotation of the tumour may take 
place, and the pedicle be twisted — an event which may similarly, by 
the same or similar causes, be many times repeated; thereby the ves- 
sels are liable to be occluded. Partial closure both of arteries and 
veins limits circulation and nutrition, and may materially restrict the 
development and growth of the tumour. But the circulation is less 
obstructed in the arteries than in the veins ; whence may result ascites 
from serous effusion through the coats of the latter on the external wall 
of the tumour ; or veins may rupture externally or internally, but in a 
limited degree for the tension is not severe. If externally, the blood 
coagulates between the sac wall and the adjacent peritoneum; these 
cohere, vessels form, and the venous return is thus facilitated, and the 
vitality of the tumour perhaps preserved. The adhesions prevent 
further rotation of the tumour, which may have been partial, so that the 
cyst may occupy a fixed position on the side opposite to its own. Such 
adhesions restrain the movements of intestine and omentum to which 
they may be attached ; and varying degrees of obstruction to the passage 
of flatus and faeces may be produced : at a later stage stretched bands 
may tightly constrict the bowel, strangulating it, compressing the veins, 
and causing actual rupture or serous effusion from them into the abdom- 
inal cavity. The future growth may be slow, and is subject to these 
adhesions ; and perhaps not till an advanced period of life are such 
results produced that the presence of the tumour is first discovered. 



I30 SYSTEM OF GYNAECOLOGY 

Should the veins be occluded by a more complete or more repeated 
rotation, an intense engorgement immediately occurs ; veins on the 
interior of the cyst wall rupture, and the sac is filled with blood, 
whereby sudden enlargement and perhaps rupture of the sac take place ; 
the abdominal cavity may then be filled with blood and ovarian fluid, 
and the woman faint or die. If there be venous rupture also on the 
outside of the sac, but without rupture of the sac, peritonitis and adhe- 
sions occur, which partly nourish this surface : the tension of the walls 
effects their necrosis ; and by transudation of the necrosed fluids through 
the distended sac wall into the abdominal cavity an acute or chronic 
peritonitis will result proportionate to the predominance of absorption 
or exudation : these factors are determined by the quality and quantity 
of the fluid transuding, and by the degree of internal tension. 

If the arteries and veins be closed at once by the compression of a 
twist, no more blood enters the tumour, and it tends to necrose by lack 
of nutrition. As it necroses, transudation of its fluids produces peri- 
tonitis, and fibrin is exuded which, by its development of vessels, may 
effect such a nutrition as to maintain just so much vitality of its sur- 
face cells that a slow absorption occurs ; the tumour decreases in size, 
and remains in a stagnant condition. Such complete closure of arteries 
is rare in comparison with that of veins, as these are more readily com- 
pressed by an earlier rotation. 

By a continuous pressure on a bony angle — as on the sacral prom- 
ontory — of a tumour of which a part occupies the sacral cavity, and 
part of the abdominal cavity, there may be by limitation of circulation a 
thinning of the sac wall at this site which may result in necrosis ; rupt- 
ure may occur, and the fluid escape into the abdominal cavity. The 
same result may follow extreme distension from venous rupture due to 
a twisted pedicle, or from a sudden blow, or fall. If the fluid itself be 
bland the resulting peritonitis may be slight, but more or less pro- 
gressive according to its quality and quantity, and the degree of infect- 
ing necrosis which may presently occur in the ragged edges of the torn 
wall, combined with the influence of systemic depression and abdominal 
pressure effected by the haemorrhage from vessels which may also be torn. 

A further degenerative cell multiplication may induce papilloma ; 
and one still lower, cancer, with peritonitis by invasion, haemorrhage 
and serous effusion into the peritoneum. 

Papilloma of the genital organs — which is a progressive multiple 
development of ectodermal or entoderm al epithelium, enclosing a vas- 
cular loop formed of a capillary terminating in a small vein and thus 
forming a papilla — is liable to be produced by an irritation which 
induces an increased growth in any part of the genital organs. About the 
vulva the cause may be the irritation of syphilitic discharge ; at the ori- 
fice of the urethra, of the friction of coition or masturbation, or exposed 
urethral membrane ; in the bladder, of urinary crystals or decomposi- 
tion ; in the vagina, occasionally, the hypernutrition of pregnancy ; and 
in other parts of the genital organs — as in the uterus, tubes, ovaries, and 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 131 

in their tumours and peritoneal coverings — papilloma may arise from 
local irritation and vascular proliferation. In connection with all internal 
papillomas the veins are liable to be large and varicose by direct pressure or 
bending on the cardiac side. When occurring on the internal aspect of a 
cyst, by complete local venous obstruction, or perhaps from deeper exces- 
sive cell proliferation, papilloma may undergo limited necrosis and thus 
suppurate. On the peritoneum, friction of its delicate structures usually pro- 
duces serous effusion, and perhaps haemorrhage, into the abdominal cavity. 

Myoma, which is a proliferation of unstriated muscular fibres enclosed 
in a connective tissue capsule, and usually multiple, is attributable to 
absence of pregnancy, from whatever cause, in a woman of strong sexual 
development: the nutrition, which should be absorbed in the devel- 
ment of the pregnant uterus and foetus, is expended in the morbid local 
proliferation of muscular fibres. 

While the muscular fibre proliferation has proceeded a sac has been 
formed also, usually by a similar multiplication of connective tissue 
cells, which surrounds the myoma, enlarges with the progress of the 
muscle fibres, and yet maintains such strength as continually to con- 
strict the supplying vessels and retard the growth. Yet this is not 
necessarily the case ; for occasionally a myoma rapidly grows in the 
absence of synchronous connective sac development, and has the exact 
form and red appearance of the pregnant uterus ; and, in the oedemar 
tous myoma, the rapid enlargement by serous or lymphatic infiltration 
of the inner structures so distends and softens the sac that its density 
is diminished. In the former imrestricted form is seen the more exact 
tendency toward the pure uterine growth of pregnancy, though the 
stimulation of the o^^im is absent. 

The effects of such diseases depend upon the situation of the 
original fecundity of the muscular growth, and thus of the direction of 
increase and prominence of the tumour. If such situation be nearer 
the endometrium the direction of least resistance is toward the cavity 
of the uterus, and the tendency is to the polypoid form ; by recurrent 
rotation due to muscular contraction, a long thin pedicle may be formed. 
the vessels of which by such continuous pressure may become occluded, 
and the poh^'pus die and become septic ; or muscular contraction ma}'^ 
expel the polypus into the vagina. If more central the tumour is inter- 
stitial. If in the external part of the muscular wall it grows outwards ; 
when also the pedicle may gradually be lengthened, thinned, and com- 
posed only of vessels covered with peritoneum : or it may be divided, 
either by the drag of its impaction in the pelvis while the myomatous 
bodj^ grows upwards, or by compression of the pedicle against the sacral 
promontory, or again by rotation of the subperitoneal tumour. The 
pelvic tumour thus separated ma}* either undergo a vital degeneration 
by the encroachment of connective tissue adhesions resulting from the 
peritonitis induced in the process of the occlusion of the vessels of the 
pedicle; or may necrose, inducing peritonitis and septic absorption. 

By cessation of arterial supply, produced by pressure on the vessels 



132 SYSTEM OF GYNECOLOGY 

by the tension of the connective tissue capsule of the tumour, generally 
interstitial, the central cells may be so deprived of nutrition that they 
necrose ; if the nutrition be deficient, but still exist to some degree, a 
degeneration, fatty, purulent, or calcareous, may occur. If the veins be 
partially compressed at some point, or in the progress of growth of the 
tumour be kinked, the distal parts become varicose, and the tumour 
from which they are efferent may become oedematous. Cysts may also 
be formed by the rupture of veins from a similar cause into the myoma- 
tous substance, when the cavities thus formed may be found to contain 
blood ; or, later, after absorption of the colouring matter, a straw-col- 
oured fluid. By occlusion of the veins of the uterine cavity by pressure 
of a submucous or encroaching interstitial myoma their walls may rupt- 
ure, and haemorrhage, called monorrhagia, result : this is particularly 
apt to occur at the menstrual epoch, when the veins are specially en- 
gorged ; but it may be continuous, in relation to the continued pressure ; 
or recurrent, when the blood has been reformed : in the intervals fibrin 
may escape, which may be coagulated or not. With this there may be 
intense dysmenorrhoea from the small size of the external uterine open- 
ing, which latter, indeed, may have been the original cause of the steril- 
ity, and so of the myoma. 

By similar obstruction to lymphatics, so that their spaces dilate and 
may become of considerable size, the tumour is rendered myomato-cys- 
tic; through rupture of the cyst walls large yellowish coagulated clots 
of their secretion may escape by the uterine canal. Thus in the same 
specimen may be found an oedematous as well as a hard myoma, the 
condition of either being dependent on the individual relation to ob- 
structed veins or lymphatics, or both. 

Suppuration may follow septic puncture. 

The encroachment of myoma in direct growth, or combined with 
.artificial abdominal pressure, by bending the uterine ends of the Fallo- 
pian tubes, frequently occludes them, so that the secretions cannot 
<escape along the genital canal. Tubal distension then occurs, and there 
is presently some effusion at the fimbriae, whereby is produced a peri- 
(tonitis proportionate to the quantity and quality of the effused fluid. 
Fibrin may be thus exuded, and such adhesions formed as bind down 
ithe fimbriae and occlude this extremity ; thus the mid-tube may become 
dilated by subsequent collection. Should the tube be septic or gonor- 
rhoeal, the further progress is that of pyosalpinx, which, by rupture, may 
cause a fatal peritonitis. Or, the tumour in its growth may spread out, 
elongate, and flatten the tubes, and render the fimbriae oedematous : a 
frequent local peritonitis may occur from their congestion and effusion. 

Myoma frequently and when of any size usually compresses the 
ovaries, so that they perform their functions with difficulty ; and local 
peritonitis occurs by the rupture of the irritated Graafian follicles into 
the peritoneum, since on account of the pressure the tubes cannot apply 
themselves. As their tunics have previously become thickened by the 
peritonitis .induced by the fimbrial effusion above described, as well as 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 133 

by that resulting from their own rupture, the follicles presently fail to 
rupture, and follicular cysts are produced, which undergo further evolu- 
tionary changes. The continuous degenerative irritation may induce 
malignant disease, which indeed is particularly liable to originate in the 
endometrial glands. 

Myoma may occur in the ovary, by similar lack in sterile women of 
normal utilisation of blood ; and an excessive development of connective 
and fibrous cells may produce a fibroma of the uterus or ovary. 

Sarcoma, originating in connective tissue derived from the meso- 
derm, has as its cause the constitutional tendency to multiplication of 
embryonic connective fibre cells; when of the ovary, it is perhaps a 
morbid reversion to a lower type in the direction of the formation of 
ovarial laminse, which have not the capacity of development into the 
higher connective tissue structure : there is proliferation without organ- 
isation. The ovary is occasionally, though rarely, thus affected, and 
apparently in relation to sterility. 

Cancer, which is a continuous cell proliferation of amoeboid type 
invading the lymphatic spaces and vessels, and always originating in 
epithelium derived from the ectoderm or entoderm, has its cause in 
such conditions as induce excessive formation of cells of degenerating 
quality. Should the constitutional state permit such degeneration to 
descend to the lowest amoeboid type, constant multiplication takes the 
place of evolution; and this tendency is exaggerated by the occurrence 
of obsolescence, and therefore of defective nutrition of these organs, at 
the most common period of cancerous development ; namely, at or about 
the menopause. Such sites and conditions are exceedingly common 
in the chronic granular hyperplastic face of the lacerated cervix, in 
which, unless healed by operation, cell proliferation terminates only 
with life ; and the cancerous degeneration is possible at any time. In 
endometritis the same chronic glandular irritation may persist; and 
ensuing malignant disease occur but a few months after parturition in 
young women from hypernutrition and excessive cell proliferation with 
degeneration at the placental site from puerperal deciduoma; changes 
which may be associated with frequent haemorrhages, leucorrhoea, subin- 
volution, and constitutional tendency to cell multiplication of rapidly 
descending cell type. Or the cancerous phase may be delayed in less 
feeble capacity of cell organisation, but be attained by a slower yet 
progressive exhaustion through the same constant drain on the system. 
But cancer is less frequent in the body of the uterus, a part which is 
not exposed to the friction against the vagina, a friction which irritates 
the granular cervical face, and thus increases cell production. Nor does 
it occur on the granular laceration of the prolapsed cervix, because cell 
proliferation there is greatly limited by the dryness of the situation. 

The continued irritation of a myoma may produce a constant pro- 
liferation of a primary or embryonic type. Should this occur in the 
connective tissue element a sarcoma of the round-celled variety is pro- 
duced ; if in the musculo-connective tissue the sarcoma is spindle-celled ; 



134 SYSTEM OF GYNAECOLOGY 

if in the glandular structures of the endometrium a cylindrical-celled 
epithelioma may arise. 

By the invasion of the lymphatic vessels, and pressure on veins by 
the excessive multiplication of cells, oedema and local haemorrhage result. 
The continuous increase presently so occludes the arteries that central 
necrosis is produced ; at the periphery of this the open ends of the vessels 
may bleed extensively from inability of their muscular layer, which is 
infiltrated by the cancerous cells, to contract. Nature's endeavour to 
separate the slough towards the outer edge of the continuous low cell 
proliferation — a proliferation too degraded in character to form healing 
granulations — when retained in healthy passages, as in the vagina, re- 
sults in a dirty foetid discharge, which is in some degree absorbed ; thus, 
and by haemorrhage, the s^^stem is drained, enfeebled, and poisoned. 

The excessive cell proliferation, around the nerves as well as in the 
substance of them, effects such compression of them that intense agony 
ensues ; this is worse at night, either because the recumbent position 
increases the weight on the nerves, or because the nervous system, at this 
time exhausted by the waste during the day, is less resistent to the prop- 
agation of the diseased actions. This pain is usually referred to the 
lumbar region at the site of the entrance of the vaginal and pelvic plexus 
to the spinal cord. 

The pressure of the tumour on the adjacent bladder and rectum may 
impede the passage of their excretions, and thus abdominal distension 
by gas and retention of fseces may affect the appetite and digestion. 

Extension of the disease to the peritoneum by local irritation produces 
peritonitis, by interstitial cell proliferation it produces venous compression 
and serous effusion, and, by arterial obstruction,necrosis,rupture of vessels 
into the peritoneum, and thus increased temperature. The advance of the 
growth into adjacent organs, as into the rectum or intestines, by narrow- 
ing them, may produce obstruction ; and subsequently, with or without 
obstruction of them or of the bladder, necrosis of the cancerous structure 
may occur, and the contents of the viscus may be discharged through an 
open sloughing hole. Further extension through the lymphatics and 
veins effects the transference of malignant cells to other more distant 
organs, which there become the foci of fresh similar growths; thus by 
continuous excessive cell proliferation, necrosis, septic absorption, haem- 
orrhage, serous discharge and pain, the system is finally exhausted. 

II. The conditions too often incident to the education of the mind 
may materially and injuriously affect the physique of women in civilised 
life. For six, eight, or more hours a day during eight or nine months in 
the year, the girl is in a room indoors where are many others, so that the 
air is frequently impure. The arms and legs are at rest, and in cold 
weather are chilled and the circulation impeded, so that chilblains, even 
where there are no frosts, are common. The stooping posture over desk 
or book, in drawing or at the piano, produces one general curve of the 
vertebral column instead of the normal three upper compensating smaller 
curves ; and frequently, by fatigue, weariness, or defective eyesight, some 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 135 

lateral curvature is established. There is an increased attraction of 
blood to the brain, and great call upon the mental powers. Exercise is 
neglected, and may consist of a constitutional walk in pairs, a mode which 
is foreign to the natural habits of young people ; thus there is long 
physical repose and merely formal exercise at an age of naturally almost 
constant, free, untrammelled play and muscular activity. Personal 
competition, culminating in place examinations, may favour the egoistic 
temperament instead of the altruistic, instead, that is, of the care for 
others, as of the next generation, which normally is a strong feminine 
characteristic. In large public schools for both sexes the close associa- 
tion of young people may induce an injurious sexual knowledge and 
desire, conscious or unconscious, without the opportunity of lawful or 
moral satisfaction. 

But the individual type must dominate all such educational habits, 
however it may be thereby modified ; and it must always be remembered 
that the strongest instinct in woman is the sexual — not necessarily the 
sexual appetite, but the production of the next generation ; thus there 
may be strong or feeble sexual development with a feeble or strong 
l)hysique ; in either case with high or only moderate mental attainment. 

The general effect of the educational course then may be to develop 
mental at the expense of physical power, and especially of the muscular 
power, and the strength of the vertebral column ; by diminished demand 
on the elements of nutrition, to reduce the appetite and the powers of 
digestion, and thus the quality of the blood ; and to favour constipa- 
tion, faecal absorption, ansemia, and irritable and hypersensitive nerves. 
The important function of menstruation is thus readily deranged ; 
and irregularities, such as menorrhagia by deficiency of coagulation, or 
of strength of the veins in the strongly sexually formed, or amenorrhoea 
in feebly developed sexual organs, arise; and, if the mind be of the 
artistic or aesthetic kind and non-passionate, the sexual organs fall in some 
degree into abeyance, and may subsequently remain feeble ; there may be 
disgust at marital rites, and a tendency to hereditary sexual degeneration. 

III. Personal Habits. — There is no such care taken by us at the 
menstrual epochs as among some other races, where the women seclude 
tliemselves, so that the function is quietly performed. With us it is not 
unusual for a woman to inject cold water or to take a cold bath to stop 
the flow for social or sexual purposes. The feet, clad in thin shoes, often 
become damp and remain so, and in cold seasons are habitually chilled 
through the soles. The evaporation of perspiration in cotton under- 
clothing abstracts much heat from the body and chills it, and the legs 
are but little protected from cold winds. 

Any of the above causes may produce contractions of the si^perficial 
vessels, with engorgement of the deeper, thus throwing on the latter the 
necessity of reactionary contraction, which they may be unable to per- 
form. An unequal state of blood-supply thus occurs in the body, and 
the defending army of phagocytes and leucocytes may be unable suc- 
cessfull}^ to combat attacking bacilli, whose victory is proclaimed in the 



136 SYSTEM OF GYNECOLOGY 

statement that a cold has been taken, a cold which may be the beginning 
or further bacillary successes in this enfeebled condition. Or the deeper 
vessels may be unable to bear the undue strain of such engorgement, and 
their coats yield, producing haemorrhage or hsematocele ; or again, irregular 
contraction of muscular fibres, as of the Fallopian tubes, may occur, so 
that their secretions, mucous or menstrual, may effuse from the fimbriae, 
and peritonitis result — in this case probably in connection with some 
lower uterine stenosis. 

In the case of vaginal injection of cold or very hot water during 
menstruation a similar local vascular contraction maybe induced without 
subsequent reaction, and the flow may cease ; this sudden shock may 
subsequently induce such a local depression of the circulation that the 
ovic maturation and catamenial discharge may cease for a long period, 
and the system suffer from the local anaemia and functional arrest. 

But of all injurious influences to woman, to which is attributable the 
great mass of the disease now so prevalent, is the extraordinary custom 
of the alteration of the form of the body, and of the position and rela- 
tions of the internal organs, by the almost universal custom of compression 
of the lower thorax and abdomen; were this done to animals, we should 
recognise its amazing injury and absurdity. The busk is a very powerful 
lever — the power of which woman does not understand ; by it she always 
compresses her body from 1 to 3 inches ; and frequently, especially when 
stout, and therefore more subject to the injurious influences of com- 
pression, 4 to 6 inches. The dress is similarly tight, and usually cannot 
be fastened unless the stays have effected previous compression. 

The influence is markedly accentuated by the attachment of the 
skirts and petticoats around the waist and abdomen which have to 
support them. These usually weigh from four to six or eight pounds, 
and react especially on the organs of the abdomen and pelvis. 

Such compression affects the muscles, and invariably displaces the 
organs of the body to an extent proportionate to the degree of pressure. 

The traction force required to approximate the busks in a natural 
separation of from 

1 to 2 inches is from 8 to 20 lbs. 



2 to 3 


11 


,, 20 to 40 


3 to 4 


11 


,, 40 to 60 


4 to 5 


11 


„ 60 to 80 


5 to 6 


11 


,, 70 to 90 



I am informed that the compression thus exerted on the body is 
represented by half these weights. Thus a woman who draws in her 
stays from 3 to 4 inches, a very common custom, places herself under 
a direct pressure of from twenty to thirty pounds weight. But this does 
not allow for the extra pressure produced in drawing a deep breath, 
when the approximated busks, under even the heaviest of the above 
weights, will readily part from half an inch to an inch. This, however, 
is impossible when the busks are fastened, and this additional pressure 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 137 

also is therefore exerted directly downwards on the pelvic organs. There 
is additional increase of pressure by the weight of the skirts and petti- 
coats, and by food or liquid taken into the stomach ; when intestinal gas 
fornis from induced indigestion, the condition is thereby accentuated. 

The spinal column is placed in splints upon which it tends to rely, 
and its movements are limited; the muscles, therefore, atroj)hy by 
deficient use, so that the woman says her back would break if she did 
not wear them. By the bending of the back in her education, and the 
wasting of the muscles by the wearing of stays, the normal curves of the 
spine are frequently lost and abnormal curvatures induced. The general 
strength of the body is thus reduced. Similarly, the pressure on the 
abdomen forces down the intestines, stretches the lower abdominal 
wall, and renders its muscles atrophic ; hence an important reduction 
of reflex and voluntary muscular power in labour. The compression of 
the lower ribs forces up the diaphragm, squeezes the lungs, and dis- 
places the heart, so that fainting from this cause is not uncommon. The 
kidneys are affected proportionately to the degree in which the lower 
ribs approach the iliac crest. If the ribs be high, their indentation on the 
upper half of the kidney displaces it downwards, stretching the connective 
tissue which attaches it in its bed of fat; it is then said to be movable; 
and, from the variable pressures to which it is subjected in the wearing 
and non-wearing of the stays, it is apt to be painful : the right kidney, 
being usually the lower, is most frequently thus displaced. The liver 
is flattened by the ribs, perhaps indented by their edges, and often 
extends to the level of the umbilicus ; the bile ducts are compressed, 
and constipation and, occasionally, jaundice result. The stomach is so 
squeezed that, when food is taken after the stays have been put on, 
there is no opportunity for its normal enlargement thereby, nor for the 
long process of churning essential to normal digestion ; thus the food is 
passed on into the intestines in a partially digested form ; dyspepsia 
follows, and a tendency to ulcer of the stomach by vascular stasis due 
to the long-continued pressure. The small intestines are depressed, and 
receive the ingesta in an abnormal state ; so that putrefactive changes 
occur in them, which produce flatulence and distension; compression 
about the ilio-csecal valve influences appendicitis. The transverse 
colon is forced do^vnwards, tending to produce obstructing angles at its 
junction with the ascending and descending portions, which are depressed ; 
and thus impairment of the peristaltic movements, flatulence, and con- 
stipation ensue. The rectum is compressed by the pelvic contents, so 
that the fceces tend to be unduly retained. Thus it comes about that 
digestion is impaired, flatulence arises, constipation is produced, the 
moisture of the faeces is absorbed, the blood is depreciated in quality and 
rendered impure, nutrition of the body falls, and the muscular force is 
reduced ; the teeth become carious, which reacts on the digestive func- 
tions; the nerves are debilitated, and neuralgias ensue; menstruation 
is disordered, and the general evils of anaemia result ; the capacity of 
the bladder is reduced, rendering micturition frequent, and subsequently 



138 SYSTEM OF GYNECOLOGY 

often painful and necessitous. If the uterus be strong, and the bladder 
not subject to much distension, relieved perhaps by frequent micturition 
set up by crowding of the parts, the pressure of the intestines forces its 
body forwards and downwards into a horizontal position, and the cer- 
vix is apt to follow the anterior course of the body, the whole organ 
rotating forwards on a transverse axis, so that it is anteverted; thus 
the body unduly presses on the bladder, and additionally irritates it, while 
the face of the cervix is subject to friction on movement against the 
posterior vaginal fornix, when there is aggravation of the virginal granular 
face, previously described, and degenerative diseases often ensue. Or, 
perhaps by rectal accumulation, the cervix is pushed forwards, more 
often into the perpendicular position, and anteflexion results. If the 
uterus be of feeble development the body has already fallen forwards ; 
but, by the pressure, the condition of anteflexion is accentuated. 

Or a strongly developed uterus may be unduly retroposed by the 
flattening from above of the bladder ; the forcing down of intestines into 
the pelvis tends to depress it into a lower pelvic plane, and the usual 
retention of faeces in the rectum presses the cervix forwards, inducing 
a rotation of the strong uterus backwards on a transverse axis at the 
junction of the cervix with the body ; thus the retroversion is completed. 
The virgin uterus rarely proceeds further, because of the strength of its 
posterior wall; but in the parous, if subinvoluted ligaments and connective 
tissue permit the rotation to proceed, the uterine body may descend to a 
much lower plane of the pelvis, so that the fundus presents downwards 
and backwards ; and, if the organ be of strong construction, the pelvis 
capacious and the vaginal structures subinvoluted, the cervix may 
maintain its normal line with the body of the uterus, and the os present 
upwards and forwards toward the anterior vaginal fornix — the extremest 
possible condition of retroversion. 

Or, instead of the continuance of the normal relative continuity of 
direction of the body and cervix of the organ, from its subinvolution and 
consequent flabbiness of tissue and pelvic resistance to the rising of the 
cervix, an angle of flexion at the cervico-corporeal junction, or even 
somewhat higher, may be formed, and retroflexion ensues, the body being 
perhaps horizontal and the cervix perpendicular. A further stage is at- 
tained when the body and fundus descend lower, so that the body and cer- 
vix tend to become parallel ; this is the more induced and accentuated by 
the continued abdominal pressure on the convexity of the angle of flexion, 
so that their impaction in the pelvis results from extreme retroflexion. 

The Fallopian tubes are liable to be bent at their junction with the 
uterus by the misplacement of the uterus in combination with pressure 
downwards of the intestines by the stays and dress. Thus in the sexual 
engorgement in love-making, with or without union, in women of warm 
appetite, this abnormal relation of the tubes to the uterus may induce 
effusion of their secretions into the peritoneum, particularly during 
menstruation, and a local peritonitis ; otherwise, they would pass in the 
normal direction through the genital canal. 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 139 



The ovaries are depressed, and forced into a latero-posterior position, 
carrying the fimbriae with them by the attachment of the tnbo-ovarian 
fimbria. Thus, by the pressure of the ovaries, the fimbrise may be 
flattened, rendered oedematou-s, and unable to apply themselves to the 
G-raafian follicles ; these discharge into the peritoneum, and may, by a 
valve-like opening occurring from the compression, produce a recurrent 
peritonitis of some severity. 

In pregnancy the stays are often worn very tight so as to conceal 
the condition ; thus miscarriages and premature confinements may be 
brought about by the accentuation of the normal rhythmic uterine con- 
tractions, by induced dilatation of a previously lacerated cervix, or by 
rapture of the membranes. By pressure on the abdominal veins by 
depression, or repression on the vena cava of the pregnant uterus, vari- 
cose veins are induced, the legs and vulva become oedematous, the veins 
may rupture, and vulvar or pelvic haematocele be produced. 

The pressure on the foetus may alter its presentation; pressure on 
the uterus may enfeeble its structure, as well as that of the accessory 
muscles of labour, which may be thus ineffective; forceps are now 
applied in the women's hospital in Melbourne once in nine confine- 
ments of all cases, and in private much more frequently. 

There is such a forcing downwards of the uterus on the ligaments as 
must tend to stretch them, and render depression of the uterus to a 
lower pelvic plane and axis more ready after labour, leading to subin- 
volution, misplacements, and prolapse. 

Thus by the wearing of tight stays the whole system of the woman 
is enfeebled, the pelvic sexual organs are apt to be misplaced, and the 
basis is laid for that evolutionary disease and sterility which are now 
so common. 

Another mode of injury by compression is the use of the tight 
binder after labour. No doubt that a very firm pressure on the body of 
the uterus is, in civilisation, frequently necessary immediately after the 
end of the third stage, in order to prevent or stop post-partum haemor- 
rhage, common from the above-mentioned causes ; but in a couple of 
hours after the cessation of the haemorrhage this danger is past, when 
binder pressure becomes injurious without compensating advantage. 

After the passage of the child the walls of the cervix for a time 
commonly lie in a state of muscular relaxation, so that an excessive 
abdominal pressure tends to evert the internal cervical or endometrial 
structure through the cervical opening. Very much more is this the 
case when the cervix has been lacerated, whereof the only satisfactory 
mode of healing is by first intention ; to this result e version must be 
fatal. To such a cause, which also bends the uterine veins, is often due 
the prolongation of the red lochia ; and by the irritation of tension on 
the angles of lacerations deep into the vaginal junction, an inflamma- 
tion of the connective tissue of the broad ligament ensues, which might 
otherwise have healed by a primary and softer union. The undue 
pressure, too, on the tubes thus crushed between the large uterus and 



HO SYSTEM OF GYNECOLOGY 

the pelvis may induce an effusion from the fimbriae which may cause a 
peritonitis, perhaps of mild character, but sufficient to induce an exuda- 
tion of fibrin, which may bind down the appendages and uterus. 

The ligaments of the uterus are maintained in a state of tension ; the 
relation of the veins, which are of great size, is altered, and the circulation 
through them to some extent obstructed, perhaps inducing thrombosis ; 
the uterus is unduly congested, and its involution impeded. On diminu- 
tion in size of the uterus, so that it regains a position in the pelvis, it is 
still large ; the subsequent pressure by the stays and the perpendicular 
position of the woman depress it into a lower plane and more perpendicular 
axis of the pelvis, and into the state of retroflexion, as previously described. 
Thus under the influence of a continuous tight binder and subsequent 
tight stays the condition presently found may be one of deep laceration 
with everted granular faces, perhaps some connective cicatricial thicken- 
ing in one or other broad ligament, subinvolution and retroflexion of the 
uterus, perhaps with such adhesions as bind it down. Such influence 
may also affect the column of the vagina and its connective tissue, and 
extend to the vulva and perineum, rendering them also subinvoluted. 

The large abdomen of the parous is frequently due to the predisposing 
influences of the unnatural habits before mentioned, which create a dis- 
position to undue flatulent distension of the intestines; this, combined 
with the pressure on the waist by the petticoats and skirts, farther 
forces down the lax abdominal walls, and accentuates the gaseous dis- 
tension. These causes are aided by that excessive fat in the abdominal 
walls which results from deficient exercise and work. 

The application of a tight binder which depresses the uterus is dis- 
tinct from a well-regulated bandage which serves normally to support 
the abdominal walls. 

The conditions present to those who give themselves to the life of 
society are that they expose their necks to the suddenly varying tem- 
peratures of heated ball-rooms, corridors, verandahs, and gardens ; they 
wear their dresses exceptionally tight ; healthy exercise is usually defi- 
cient, but there is over-exertion ; from the great and almost constant 
excitement there are undue nerve tension, and, not seldom, disappoint- 
ments ; the diet is irregular, and dainties are preferred ; the hours are 
late ; sleep is irregular, and taken at abnormal hours ; repose of body 
and mind are deficient. 

The effects are apt to be that colds are taken, and are with difficulty 
shaken off ; the appetite is impaired, digestion enfeebled, and constipation 
established; the formation of the blood is injured, anaemia and general 
debility ensue ; the catamenia become irregular ; the nerves are impov- 
erished, so that neuralgias and hysteria arise, and the weight declines. 
Such parous women are apt to suffer from subinvolution with endometritis 
and its consequences for reasons previously mentioned ; and the milk is 
liable to be deficient in quantity, or of excessive quantity and of feeble 
quality, so that the systems of both mother and child are impoverislied. 

The diets that act injuriously are the defective and the unfit. It is 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 141 

common among young girls of delicate constitution and temperament to 
have an apparent pleasure in refusing plain healthy food, or a necessary 
quantity of any kind. Thus some will take no breakfast, or only a glass 
of Avater ; milk and meat are refused ; and this refusal appears to be- 
come a point of honour. Single women from thirty-five to forty-five 
years of age, and women upon whom is a great drain of child-bearing 
and lactation, may similarly decline animal food. 

The improper diets among young girls may include eating unripe 
fruits in place of ordinary food ; or pastry, cakes, and sweets at irregu- 
lar hours. Older women, especially in warm climates, frequently drink 
large quantities of very hot strong tea, or of water. All such aberrant 
diets tend to dyspepsia, flatulence, constipation, anaemia, and amenor- 
rhoea ; and in the parous also to subinvolution with endometritis, and 
their consequences. 

IV. The influence of absence of marriage, and late marriage, which 
are the tendencies of our age ; and of ineffective marriage, which includes 
artificial prevention of pregnancy, are highly deleterious. The due age of 
marriage certainly varies according to climate, and in that of Great Britain 
the perfection of development is from twenty-three to thirty ; but at the 
age of thirty half the women are yet unmarried, so that about half of the 
period of their capacity of propagation has already passed. While many 
women in civilised communities are signally deficient in sexual appetite, 
many are normally developed in this respect. Such due appetite may be 
strongly present in girls of plain features, who are unattractive, ill- 
nourished, and depressed ; and it is perhaps particularly in these that 
a normal temporary congestion and unsatisfied desire lead to injurious 
habits which produce chronic congestion, endometritis, and the like. 

The common effect on the physique of postponing marriage is to induce 
a general atrophy; the fat, which imparts the rounded outline to woman, 
falls away and she becomes angular, her muscles and tendons are distinctly 
outlined, and markedly noticeable about the face and neck ; the quality 
of the blood has suffered, and anaemia may have resulted ; the nutrition 
of the nerves has been impoverished, and neuralgias and hysteria are 
common ; the catamenia may have become irregular, and be either in- 
creased or diminished according to the temperament ; and leucorrhoea 
may have resulted from desire unsatisfied by marriage or pregnancy. 
Some women who have a good sexual formation, except for a small 
external uterine opening and deficiency of sexual appetite, grow fat, the 
catamenia decrease, and the organs atrophy from absence of employment. 

But the influence of the normal impulse to the production of the 
next generation is amply demonstrated in sexually well-developed persons 
who from non-marriage have not become pregnant ; or who, from whatever 
cause, have ceased for a long time to bear children ; by the frequent occur- 
rence in such persons of myoma of the uterus : in myoma the muscular 
fibres increase in many sites in an irregular manner, which, in multi- 
plication, is analogous to that of pregnancy ; indeed, in an early, stage 
its further development may be stopped by pregnancy, for the uterus 



142 SYSTEM OF GYNAECOLOGY 

has thus been employed naturally, and its nutrition engaged in its 
proper functions. 

V. Sexual Exhaustion. — Under normal circumstances in healthy 
women, coitus, though at first on marriage liable to be excessive, is usually 
limited presently by custom, and pregnancy ensues. Some husbands, and 
some women also, have an insatiable sexual appetite. Thus on the part 
of the man the act may be repeated very frequently ; or the woman may 
be subject to many men, as are prostitutes; or unnatural habits may be 
adopted; or pregnancy may be avoided, with consequent absence of 
satisfaction, and thus of relaxation. All these conditions are liable 
to cause a chronic congestion, resulting in endometritis ; or, in case of 
pregnancy, in miscarriage or premature confinement with succeeding 
subinvolution and endometritis : the induction of miscarriage, which is 
now so common, has the same effects. The frequent strain produces 
debility, and the nervous system is weakened. 

Regular child-bearing with a normal condition of the uterus and 
moderate lactation seldom injures the woman ; but when, combined with 
granular cervix and endometritis, the system is debilitated by the undue 
drain of excessive cell formation, disease is apt to ensue. 

The child-bearing which would be healthily effected in a temperate 
climate is excessive to the British race in tropical countries, in which 
the blood becomes thinner and the vessels dilated ; then post-partum 
haemorrhage, subinvolution, endometritis, menorrhagia and anaemia are 
common. 

The congestive thickening of the vaginal membrane near its poste- 
rior commissure from excessive coition may produce occlusion or steno- 
sis of one or other vulvo-vaginal duct ; the secretion accumulating in 
the more dilated part near the gland may .continue clear, and a cyst be 
formed ; or, if septic germs gain admission by the duct or through the 
blood, suppuration occurs. 

VI. Infectious Diseases. — Syphilis is said not to be conveyed to the 
foetus through the placenta, but through the germ or sperm. The foetus 
is liable to be affected in the congenital form when one or both of the 
parents is actively diseased in the second stage at the time of impregna- 
tion; after conception the father, who may have been free from symptoms 
for many months, may suffer from a syphilitic testicle, or the mother 
from a rash ; or, after a period of apparent health for perhaps twenty or 
thirty years, a parent may have a specific rash. The degree to which 
the progeny is liable to be affected is in proportion to the virulence, 
attenuation, or quiescence of the parental disease. 

The effects are seen in hereditary congenital and simple forms. In 
the former, malformations, from inflammatory arrest or deficiences of 
development, are present at birth, being induced by an inflammatory 
action in the cells, ducts, or vessels, destroying or closing them, and 
arresting development. In the latter the results, similarly caused, may 
not manifest themselves for varying periods after birth. 

The mother may, however, directly transmit measles, scarlatina, and 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 143 

small-pox to the foetus, perhaps through the liquor amnii, and the same 
results ensue (Hamilton). 

Syphilis, by irritation of its secretions, produces condylomata about 
the vulva and anus, and enlargement of the inguinal glands, with the 
consecutive affections. 

The inflammation of mucous membranes, accompanying such dis- 
eases as scarlatina and measles in which micrococci have been found, 
may attack the vagina, uterus, and tubes ; and, since the outlets are of 
small size during childhood, it may continue in a chronic form, and 
lead. to evolutionary affections of the peritoneum and ovaries. 

To gonorrhoea is to be ascribed a series of progressive diseases, which 
are liable to be as virulent as they are continuous. 

Miserable to relate, this disease is met with even among little girls. 

A young girl may, primarily, take it from a man who had the idea that 
his gonorrhoea was curable by contact of a young virgin ; and she may 
convey it to others by the fingers. It may possibly be contracted by 
other means, as by contact of the vulva with gonorrhoea-infected towels, 
closet-seats, or chamber utensils ; but, whatever the sex or age of the 
patient, there has been direct contact with the discharge of a previously 
diseased person. These young girls, perhaps but of a few years of age, 
may retain the disease for many months or even years, during which it is 
liable to advance into the higher genital organs, and produce evolutionary 
results. In this way it may be a common cause of the peritonitis of 
female childhood, and of adhesion and arrest of development of the genital 
organs, perhaps with their displacement; of the latter results, a small 
adherent retroverted uterus and adherent atrophic ovaries may be sub- 
sequently apparent as having occurred during the years of childhood. 

The vagina is, primarily, not readily subject to the affection, an im- 
munity probably due to the absence of glands in which the microbe may 
find a nidus. Thus the gonococcus at first finds a habitation in the mucous 
follicles at the orifice of the urethra or vagina, or in the sinuosities of the 
uterine cervical glands. When thus affecting the urethra an irritation 
arises, which induces a cell proliferation suitable for successful attack by 
streptococcus and staphylococcus present in the infecting matter : thus 
suppuration results, which, in combination with the gonococcus, travels 
up the urethra to the bladder ; hence follows cystitis. Should entrance 
to the ureters be effected their inflammation ensues ; and by subsequent 
contraction in healing, their stricture and hydro-nephrosis. If progres- 
sive to the kidneys, their inflammation, and perhaps suppuration, leads 
to pyonephrosis. 

Also, the canals of the vulvo-vaginal glands may likewise be primarily 
affected by the gonorrhoeal infecting matter, and abscess in them occur. 
The vagina is thus continuously exposed to the disease, and becomes 
infected; and presently, especially if the os uteri gape, the cervical 
canal. 

Or the gonorrhoeal matter may, in union, be directly injected into the 
canal of the cervix, and take up a habitation in the gland-ducts ; and the 



144 SYSTEM OF GYNECOLOGY 

vagina be secondarily infected by the downward passage of thus diseased 
secretions. From the cervix the corporeal endometrium is affected, and 
the micrococci may infest the sinuosities of its gland-tubes. Thus, 
should the vagina, vulva, and urinary canal have recovered from the 
disease, perhaps by treatment, a later downward passage of the gono- 
cocci may again infect the vagina ; hence vaginal recurrence. 

The trumpet-mouth of the Fallopian tubes renders it easy for the 
germs to enter and infect them: hence salpingitis, and the evolutionary 
affections of the peritoneum and ovaries described in detail in section 1. 

When the fimbria of a tube infected by gonorrhoea, puerperal septi- 
csemia, or tuberculosis is adherent to an ovary of which a Graafian follicle 
ripens and bursts into it, the bacteria enter the follicle and suppuration 
ensues therein ; or when an accumulation of pus occurs in the fimbria 
adherent to the inflamed, distended, thin membrane of a follicular cyst, 
the bacteria may enter it by transudation. Septic pus having formed in 
a sac of an ovary, similar abscesses occur in other follicles, probably by 
transudation of bacteria under similar conditions ; so that abscess of the 
ovary is usually multiple, though the septa between pus-sacs may break 
down and one large abscess predominate over the others, and the ovary 
becomes of considerable size. 

On increase of pus the tunic yields in the direction of least resistance ; 
and, as in pyosalpinx, on minute rupture peritonitis results, causing 
cohesion of the ovary with adjacent peritoneum, if this had not taken 
place previously. Should the attachment be to the intestine, the pus of 
the rupturing sac escapes into it ; but the other sacs of the multilocular 
abscess do not thus discharge their contents, and the inflammatory con- 
dition continues. The cause of abscess of one ovary may also apply 
to the other, and thus both may suppurate ; and, since the tubes were 
previously similarly affected, double pyosalpinx is probably also pres- 
ent : ovarian suppuration, however, being dependent on rare relations 
and opportunities, seldom occurs. 

Septicaemia is a term applied to a class of diseases induced primarily 
by the entrance of putrefactive liquids into the system through the blood- 
vessels or lymphatics : different parasitic micro-organisms in these liquids 
attack and overcome the defending army of phagocytes and leucocytes, 
live upon the blood, and secrete a toxine or poisonous miasm which 
may be fatal ; these events may arise in the puerperal state, or from 
accident or operative causation. 

In the puerperal, accidental, or operative state the site of attack is 
some laceration, wound, or injury ; as of the perineum, vagina, cervix, 
uterus, or unclosed venous sinuses or lymphatic vessels of the ovic or 
placental site, generally by retention within the cavity of the uterus of 
portions of placenta, perhaps of adherent membranes or of blood-clots. 
In the absence of the use of antiseptics, micro-organisms may success- 
fully attack the raw tissues, and in this state of endosmosis affect the 
system. They are particularly infectious in the state of comparative 
emptiness of the vessels caused by the coincident haemorrhage ; but 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 145 

when the part is granulating such absorption does not occur, the ves- 
sels are in a state of fulness and tension, and the tendency is towards 
exosmosis in relation to the growing of new tissue. 

The attack is through the veins or the lymphatics, perhaps through 
lymphoid cells, by the open mouths of which canals these micro-organ- 
isms may enter. In the former case septic phlebitis results, in which the 
inflammation is proportionate to the quantity and quality of the sepsis. 
Thus, if the cause be virulent, the tunica interna becomes suppurative, 
and the progress of the septic germs, rapidly spreading towards the 
heart, may be at intervals temporarily checked by the formation of 
thrombi. These, however, are speedily similarly affected, they disinte- 
grate, become loose in the enlarging lumen of the veins, and form the 
nidus of fresh infection which permeates the body and especially affects 
synovial membranes ; death is the result. If the sepsis be less virulent, 
the thrombi may maintain a firmer attachment to the venous inner walls, 
but are liable to become loose and block the heart, or form the nucleus 
therein of larger coagulations ; or they may form infarctions in the lungs, 
producing pleuro-pneumonia ; or clotting may advance toward the heart 
by gradual vein-wall infection, so that thrombosis may extend from the 
uterus along the uterine and ovarian and, on the left side, the renal 
veins ; and perhaps on both sides it may extend into the vena cava, and 
thence, on the right side, perhaps infect the right renal vein. Or per- 
haps in only one vein in the broad ligament a septic thrombus, guarded 
toward the heart by a sufiiciently healthy adherent clot, may suppurate, 
burst through the venous coats, infect the connective tissue, and pro- 
duce a pelvic cellulitis, discharging in the direction of least resistance. 

Should a virulent septic absorption take place, especially through 
lymphatic vessels, the blood may at once be so affected, probably by 
secretion of bacterial toxine, that it becomes disorganised, and death 
results from general acute septicaemia. A less virulence gives time to 
permit septic inflammation of special structures, as of serous or mucous 
membranes ; or a local suppuration from septic retention in a lymphatic 
gland in a broad ligament forming suppurative cellulitis ; or, in a less 
septic degree, resulting in inflammatory induration and resolution. 

The common cause of puerperal peritonitis is the effusion of septic 
fluid from the fimbria infected by continuity from the uterine cavity. 
Thus the slight primary oozing may cause a peritonitis, inducing fibri- 
nous exudation which occludes the fimbria by adhesion. Should the 
quantity of fimbrial effusion be greater the peritonitis is stronger. If 
the quality be virulent and the quantity large, the fimbrial effusion 
being continuous or recurrent, the peritonitic exudation is sero-puriilent ; 
such adhesion as occurs is feeble and ineffective for occlusion, and the 
peritonitis is general and virulent. 

Or, less frequently, it may be caused by the rupture, by pressure 
of the child, of a septic suppurative salpingitis into the abdominal 
cavity; or such a tube may thus burst into the connective tissue of 
the broad ligament, producing a virulent pelvic cellulitis. 

li 



146 SYSTEM OF GYNECOLOGY 

Tuberculosis in tlie genital organs may occur either by the arrival 
of the tubercle bacillus by the intestines, by the blood, or through the 
vagina. If by the intestines, the bacilli, probably swallowed in tuber- 
cular pulmonary sputum, have penetrated the intestinal glands, infected 
the peritoneum, and thence entered the fimbria and attacked the tube, 
and perhaps spread to lower parts of the genital canal. Coincidently 
the more distant peritoneal surface, and, by deeper attacks, the under- 
lying structures of the ovaries, tubes, uterus, and broad ligaments, may 
be affected. And a nidus in the genital organs having thus occurred, 
farther advance into the heart and lungs, perhaps through the bron- 
chial glands through the medium of wandering lymphoid cells, may 
be effected. Secondarily, tubercular pus may escape from the tube 
through the fimbria, and reinfect the peritoneum. 

Or the bacilli, derived from swallowed tubercular pulmonary sputum 
or tubercular ulcerating intestinal glands, may be detained in the lower 
rectum in constipated or liquid fseces ; and successfully attacking the 
lymphoid cells, may enter lymph glands, induce suppuration around the 
anus, and produce rectal fistula. Thence by progressive lymph-gland 
disease, the connective tissue of the broad ligament may be attacked, and, 
by suppurative destruction, the peritoneum and adjacent genital organs. 

By the blood bacilli, escaping from a softening pulmonary tubercle, 
may travel in the current until they arrive at a capillary in the genital 
organs, where they may conquer a lymphoid cell and develop a tuber- 
cle, — perhaps in a lymph gland in the broad ligament, producing tu- 
bercular pelvic cellulitis. 

By the vagina bacilli may gain entrance from an adjacent rectal tu- 
bercular fistula, or other tubercular suppuration of which a sinus may 
perhaps open into the vagina, and the bacilli travel upwards. Or the 
sperm may contain bacilli, which advance and infect. Or the discharge 
of a suppurating tabercular gland, perhaps submaxillary, may be con- 
veyed by the finger of the woman within her vaginal orifice. The ba- 
cillus, having gained entrance, is attacked by a wandering lymphoid 
cell, which it may conquer ; and thus a second, gaining nutrition from 
the tissue of these cells, may enter a lymph-gland and produce tuber- 
cle, which may suppurate and break down. Should the bacilli be very 
numerous and powerful, a general infection of adjacent structures and 
infection of cardiac proximal glands ensues, and the disease has exten- 
sive foci. But if the bacilli be but of moderate vigour, a strong fibroid 
sac wall of condensed connective tissue is formed about the abscess, and 
permeation of bacilli is effectually resisted. Thus a tubercular abscess 
in the broad ligament may be coincident with a suppurating submaxil- 
lary gland without farther extension ; but a foetid bacillus may have 
infected the pus. 

When by uncleanliness, or the passage of urinary crystals or sugar, 
or of small worms from the rectum, a vulvar or vaginal irritation has 
been caused, micrococci, as staphylococcus and streptococcus, finding 
suitable nutrition, may enter the vagina and induce an inflammatory 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 147 

state called vaginitis, causing pruritus of the vulva. This occurs the 
more readily if the hymen be contracted, so that the secretions are 
retained ; or under the influence of the venous engorgement of pregnancy. 

Hydatid tumours, which are of the animal kingdom, may have a 
situation in the wall of the uterus, ovary, tube, peritoneum, or connective 
tissue {vide article " Hydatids " in Syst. of Med.']. The sexual organs are 
displaced according to the size and direction of growth of the tumour. 
By rupture or puncture dissemination of the fluid and of daughter cysts 
is eftected ; and, if into the peritoneum, fibrinous exudation produces 
adhesions which may bind down the whole tumour to adjacent structures, 
or, being highly vascular, may resemble a skein of scarlet floss-silk ; or, 
by continuous escape of necrosed contents, may set up a progressive 
and virulent peritonitis. 

VII. Accidental and operative. 

Accident, which is here used to mean the unusual effect of a known 
cause, is the common cause of vaginismus, which is the spasmodic con- 
traction of the muscles about the orifice of the vagina, producing 
dyspareunia. When the hymen is lacerated in union, its segments re- 
tract to the vaginal opening at various sites according to its formation ; 
but most generally towards the posterior commissure. Subsequent 
frequent union and irritation may prevent the healing growth of epi- 
thelium over the raw edges, which, becoming inflamed, develop hyper- 
vascular and hypersensitive papillae. Their continued irritation by 
attempted union, by the friction of walking, or by the constant bathing 
of their surfaces in the acid vaginal secretion, may maintain the condition. 
Any attempt to enter the vagina produces a reflex contraction of the 
muscles which close the opening, as of the bulbo-cavernosus muscle, and of 
the adductors of the thighs, as well as a retraction of the pelvis from the 
source of the pain. The same effect results from a similarly produced 
non-healing tear of the posterior commissure, causing a fissure ; from 
the intense sensitiveness of an angioma or vascular caruncle at the orifice 
of the urethra ; from the repeated sexual act in nervous girls full of 
sexual disgust ; and also from repeated ineffective union of a feeble 
male with a sexually disposed female inducing a hyperactive and dis- 
satisfied spasmodic muscular state. 

By direct force, as a fall or blow, cystic tumours may be ruptured, of 
which the effects are described under ovarian cystoma, and a myoma 
may be bruised, causing venous extravasation and peritonitis, and per- 
haps its necrosis. 

Of the operative causes of disease, the introduction of any kind of 
dirty instrument may convey septic germs, as of the sound tainted with 
gonorrhceal matter. Or force may effect a minute necrosis, which may 
induce inflammation, as in the attempt to pass a sound otherwise than 
in the line of the uterine canal, whence may result endometritis ; or if it 
perforate the peritoneum, as in some cases of the production of criminal 
abortion — peritonitis. 

The forcible replacing of an adherent uterus may rupture vascular 



148 SYSTEM OF GYNECOLOGY 

adhesions about the uterus or Fallopian tubes, or a follicular cyst, 
whence peritonitis. 

The application of irritants, such as carbolic acid or iodine, to the 
endometrium, particularly when the cervical canal is narrow and obstruc- 
tive, readily puffs up the glandular • structures sufficiently to close the 
inner or outer os. When the escape of the secretions is hindered, reflex 
irritation results, the muscular fibres contract spasmodically and pain- 
fully, and endometritis ensues. This is the more apt to occur Avhen 
there exists an angle of flexion in the uterus, which may be anteflexed 
or retroflexed ; and the two conditions of a narrow canal with anteflex- 
ion are usually coincident in the uterus of feeble development. Thus if 
endometritis have previously existed, it is accentuated, and evolutionary 
progress, described in section 1, proceeds. 

A yet more vigorous action in the same direction may be from the intro- 
duction of the tent, whether sponge, laminaria, tupelo, or slippery bark ; 
since necessarily, by their presence, there is a temporary suspension of 
escape of secretions, which are augmented by the pressure on and irritation 
of the endometrial glands by the part of the tent within the uterine body. 
If the condition of the endometrium, for the diagnosis or treatment of 
which the tent is used, be already inflammatory, the endometritis may be 
increased. If not, such tents, and particularly when of sponge, rapidly 
become septic, and the secretions retained in the uterine cavity are thus 
tainted, and evolutionary disease, through fimbrial effusion, may advance. 

In the dilatation some laceration of the interglandular structures 
results, and the sponge insinuates itself into the gland-ducts themselves, 
so that such raw surfaces are the more liable to be septically infected ; 
and particles of this septic sponge may be retained after withdrawal of 
the mass. A temperature of 105° may thus be rapidly produced. 

An intra-uterine stem, which is usually more permanent, is similarly 
injurious by creating or increasing endometritis by pressure and obstruct- 
ing drainage. 

Injections of fluid may be introduced into the uterus unintentionally 
by chance pressure of the vaginal tube through a lacerated or dilated cer- 
vix, and obstructing the canal, may pass through the tube into the perito- 
neal cavity, and induce peritonitis ; or intra-uterine injections, made with 
a fine tube, may be retained within the uterine cavity by angularity or 
stenosis, or hyperplastic approximation of the walls of the canal, and in- 
duce colic and endometritis ; or perchloride of mercury may be absorbed, 
and produce acute nephritis and anuria, resulting in ursemic death, due 
provision for its return not having been made; or the cervical canal 
may be thickened by the irritation and become stenosed. 

Probably few operative measures more frequently cause or exaggerate 
disease than pessaries. They are always septic by accumulation of secre- 
tion about them, and thus present to any abraded spot, which themselves 
may have created, the bacteria of inflammatory action. By continuous 
pressure on the vagina they are liable to produce necrosis, and retaining 
bands may be formed across their bars ; or they may embed themselves 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 149 

in the rectum or bladder. By constant expansion permanent dilatation 
of the vaginal muscular fibres and the destruction of the vaginal column 
may be effected ; while, if there be vaginal subinvolution, this is con- 
tinued and usually accentuated. By the separation which they cause 
the faces of the lacerated cervix are everted ; and if the upper limb in- 
sinuate itself between them a deep furrow is created, and about it the 
hyperplasia, by irritation of the interglandular structure, is increased. 
The body of the retroiiexed uterus often falls back on the upper limb of 
the pessary and becomes very tender, showing that peritonitis has been 
induced, probably from effusion from the fimbria of a compressed or 
bent tube ; and if a larger instrument be employed the preceding dis- 
advantages are the more apparent. 

When evolutionary disease has already created salpingitis, peritonitis, 
and perhaps follicular disease of the ovaries, there are usually adhesions ; 
and the pressure of the pessary on these affected parts tends to irritate 
them, and increase the rapidity of progress or recurrence of their diseases. 
Moreover, the pressure on an ovary congests it, or may effect rupture of 
a follicular cyst with resulting peritonitis. 

A metrotomy by scissors, which divides the circular muscular fibres 
so that the faces are everted, produces the effects of that degree of lacera- 
tion without subinvolution ; and induces or accentuates endometritis. If 
the operation be performed with a two-bladed metrotome, an unequal or 
excessive division may divide a vessel into the broad ligament, whence 
may result an extensive hsematocele, which may become septic ; the pas- 
sage of the knife through the lateral vaginal fornix may have similar 
results ; or, in an irregular division, the blood may escape into the peri- 
toneum. 

If the OS be closed by operation, as by excessive suturing in trache- 
lorrhaphy, or cicatrisation with contraction after a small metrotomy, the 
secretions — such as blood and mucus after coincident curettage, and the 
catamenia — are retained in the uterus and tubes, may distend them, and 
escaping through the fimbria into the abdominal cavity, produce peri- 
tonitis. This may or may not be virulent, according to the quality of the 
sepsis or degeneration and quantity of the fluid thus effused. If secretions 
be retained in the cavity of the uterus with stenosis of the os by such 
intermittent causation, they are likely to become septic, and endometritis 
results, and perhaps further disease. 

In puncture with a trocar, for exploration or treatment, if the instru- 
ment be septic, putrefactive germs may be introduced, and necrosis and 
septicaemia result ; this may happen in a myoma pierced by an explora- 
tory trocar or electric needle. 

The introduction of an exploratory trocar into a solid abdominal 
tumour is liable to be followed by peritoneal hsematocele, which, if aseptic 
and in moderate quantity, may be absorbed, and in part contract ; but if 
too large for nutrition, it may undergo necrosis and become purulent; 
it will certainly do this if septic by escape of necrosed tissue from the 
puncture in the tumour. 



150 SYSTEM OF GYNECOLOGY 

If the tumour contain fluid, some of it, and perhaps much, may ooze 
through the small opening after the withdrawal of the canula. If such 
escape be into the peritoneum, the peritonitis is proportionate to the 
degree of virulence and the quantit}^ of the fluid, as well as of the septic 
influence of the operation, an influence perhaps due to admission of air 
through the canula : similarly, pelvic cellulitis may thus be erysipe- 
latous and pyaemic. 

The withdrawal of the liquor amnii from a tubal extra-uterine f oetation 
is liable to be followed by escape of blood; and, on removal of the 
canula, some may pass into the abdominal cavity. The vitality of the 
ovum may thus be destroyed, and its necrosis occur with tainting of 
the escaped clot, whereby a progressive and finally virulent peritonitis 
is produced. 

In the operative puncture of a dermoid cyst, the canula, blocked by 
the fat and hair, may, in its removal, discharge some of the sac contents 
into the peritoneum, inducing peritonitis ; and the inflammation, extend- 
ing through the opening made, may affect the lining wall of the sac, and 
produce pus formation, or septic suppurative germs may be thus intro- 
duced directly. 

Perforation of the intestine, so that the gases and faeces escape into 
the peritoneum, is intensely and virulently inflammatory from the pres- 
ence of the bile, bacteria, and matters decomposed or ready for decom- 
position. In leaking puncture of the bladder, healthy effused urine is in 
itself non-irritating ; but if unhealthy or decomposing, or in excessive 
quantity, very irritating. 

In the treatment of abortion, undue haste may induce attempt at 
removal of the ovum before separation of the chorionic villi or placenta 
has taken place, so that part remains in a necrosing state in the uterus ; 
or curettage may be practised thereon, or deeply on the prominent 
placental site, from want of knowledge that such projection is normal. 

Any operation in which the peritoneum is opened, and septic germs or 
disorganising fluids, gases, or solids are admitted, may lead to peritonitis 
of a degree proportionate to the quality and quantity of such irritating 
agent. 

W. Balls - Headlet. 



REFERENCES 

1. Baldy. Text-hook of Gynaecology. — 2. Balfour, F. M. " On the Origin and 
History of the Uro-genital Organs of Vertebrata," Journal of Anatomy and Physiology, 
vol. X. 1876; "On the Structure and Development of the Vertebrate Ovary," Quarterly 
Jour, of Microscop. Sci. vol. xviii. 1878. — 3. Bantock. "On the Pathology of certain 
so-called Unilocular Ovarian Cysts," Trans. Obstet. Soc. vol. xv. — 4. Barnes. The 
Diseases of Women. — 5. Beddard. F. E. "Observations on the Ovarian Ovum of 
Lepidosiren," Proceed, of the Zool. Soc. of London, May 4, 1886. — 6. Bell, F. J. Com- 
parative Anatomy and Phys. — 7. Calderwood. " On the Ova of Teleosteans," Joiir. 
of the Marine Biol. Assoc, of the United King., new series, vol. ii. No. 4. — 8. Coats, J. 
Manual of Pathology. — 9. Cunningham. Journal of the Marine Biol. Assoc, of the 
United Kingdom, new series, vol. ii. No. 1 ; vol. iii. No. 2. — 10. Cullingworth. On 
Pelvic Cellulitis. — 11. Darwin. The Descent of Man; The Origin of Species. — 12. 



DIAGNOSIS IN GYNECOLOGY 



[5] 



DoRAN, Alban. " On Myoma and Fibro-Myoma of the Uterus and Allied Tumours of 
the Ov^aries," Trans. Obstet. Soc. vol. xxix. ; Tumours of the Ovary. — 13. Emmet. 
Principles and Practice of Gynsecology. — 14. Garrigues, H. J. Diseases of Women. — 
15. Geddes, p. EncyclopsscUa Brit. vol. xx. p. 408; vol. xv. p. 368. — 16. Geddes 
and Thompson. Comparative Anatomy . — 17. Gegenbaur. Elements of Comparative 
Anatomy.— 1%. Grey's Anatomy. — 19. Habershon. Diseases of the Abdome?!. — 20. 
Hamilton, D. J. Textbook of Pathology. — 21. Hart, D. Berry. Female Pelvic 
Anatomy. — 22. Kirkes. Handbook of Physiology. — 23. Minot. Human Embryology. 

— 24. Napier, Leith. "Habitual Abortion," Obst. Trans, vol. xxxii. 1890. — 25. 
Playfair, W. S. The Science and Practice of Midwifery , "On Removal of the Uterine 
Appendages in Cases of Functional Neurosis," Obst. Trans, vol. xxxiii. 1891. — 26. Pozzi. 
Medical and Surgical Gynsecology. — 27. Ruffer, A. Quar. Jour, of the Microscop. Soc. 
vol. XXX. Part 4, Feb. 1890. — 28. Savage. On the Female Pelvic Organs. — 29. Schacht. 
"On Ruptured Tubal Gestation," Brit. Gynsecol. Jour. Nov. 1893. — 30. Schultze, 
Trans, by Macan. Displacements of the Uterus. — 31. Shattock, S. G. The Morton 
Lecture on Cancer, May 19, 1894. — 32. Sxow, H. The Proclivity of Women to Cancerous 
Diseases; On Cancers and the Cancerous Process. — 33. Sutton, Bland J. Surgical 
Diseases of the Ovaries and Fallopian Tubes; Evolution and Disease. — 34. Tait, 
Lawson. Diseases of Women and Abdominal Surgery; Diseases of the OvaHes ; 
Ijectures on Ectopic Pregnancy . — 35. Thomas and Munde. Diseases of Women. — 36. 
Thornton, Knowsley. "Three Hundred Additional Cases of Ovariotomy," Med. 
Chir. Trans, vol. xx. ; "Cases Illustrating the Surgery of the Kidney," Lancet, 1895. 

— 37. Wells, Sir Spencer. Diseases of the Ovaries ; Ovarian and Uterine Tumours. — 

38. Wiedersheim. Grundriss der Vergleichenden Anatomie der Wirbelthiere,\W6. — 

39. Williams, J. W. " Tuberculosis of the Female Generative Organs," Jo7i»s Hopkins 
Hospital Reports in Pathology, ii. Baltimore, 1892. — 40. Winkel, by Chadwick. On 
Childbed. — 41. Woodhead, G. S. " Practical Pathology : An Address on the Channels 
of Infection in Tuberculosis," Lancet, Oct. 27, 1894. 

W. B.-H. 



DIAGNOSIS IN GYNECOLOGY 

The differential diagnosis of particular diseases will be found under 
their respective headings in the several articles of this volume. The 
object of this article is to collate, with a view to diagnosis, the various 
symptoms and physical signs met with in the diseases peculiar to women. 
The subject naturally resolves itself into two parts — the history of 
the patient and the physical examination ; and it will be treated under 
these headings. 

The history of the patiext. — Eor purposes of reference a note 
should be made of the date, and of the name and address of the patient. 
The investigation may be conveniently carried out in the following 
order : — 

Age. — The age of the patient ; which has a direct bearing on many 
matters — such as menstruation and child-bearing. Before the age of 
ten menstruation is naturally absent ; and again after the age of fifty : 
though even in healthy persons the dates of onset and cessation vary 
within wide limits. Impregnation occurs only during the period of 
active menstrual life. The age of the patient is often of importance 
also in deciding upon the nature of disease. For instance, cancer rarely 
occurs before thirty or forty years of age, and more often about the 



152 



SYSTEM OF GYNECOLOGY 



time of the menopause. Nevertheless, we must not forget that cases 
occasionally occur at an earlier age ; I have seen the disease in an 
advanced stage at the age of twenty-nine, and even so early as twenty- 
five. 

Social Condition. — Information as to marriage or spinsterhood, or, 
again, whether the patient be widowed or separated from her husband, 
has often an important bearing in determining the question of pregnancy, 
and in affording presumptive evidence of sexual intercourse. And the 
further information as to the length of time the patient has been 
married, widowed, or separated, as the case may be, is often a necessary 
factor in deciding these important questions. Many diseases occur 
only in connection with gestation ; others only as the outcome of deliv- 
ery ; others again follow sexual intercourse. A note of these matters, 
therefore, often provides a valuable step towards diagnosis. 

Occupation. — The occupation of the patient has often a material 
bearing upon the disease from which she suffers. For instance, cooks, 
charwomen, and laundresses, being constantly on their feet and exposed 
to a hot and often steamy atmosphere which tends to relax the tissues, 
are specially disposed to various forms of prolapse. In the case of 
married women, it is well to ascertain the occupation of the husband ; 
for many deductions may be drawn from this knowledge. The occupa- 
tion of the husband not only affords some notion of the means of the 
patient, but often leads up to some conclusion concerning the nature 
of the illness. Take, for instance, the case of a patient suffering from 
vaginal discharge, one in which it is difficult and yet important to 
determine whether the discharge be merely an ordinary leucorrhoea or 
a gonorrhoea : now there are certain classes of the community on the 
male side — and therefore on the female side also, when they happen to 
be married — who are particularly prone to gonorrhoea, such as soldiers, 
sailors, and policemen. In these cases additional information, sufficient 
to warrant a diagnosis, can usually be obtained. 

Leading Symptoms ofivhich Complaint is made. — Having made a note 
of the foregoing preliminary particulars, it is well before making further 
inquiries to ascertain generally from the patient the precise symptom or 
symptoms of which she complains. Patients often give a very indirect 
answer to the question, "What is it you complain of ? " — such a reply as 
"the insides " or " the womb " ; and they are apt to give as their answer 
(often with considerable modification) what any doctor who has been 
previously consulted may have told them. It is then necessary to inquire 
what brought her to seek advice. In the vast majority of cases it will be 
found that actual pain or discomfort in some part or other is the leading 
symptom from which the patient seeks relief. But in some cases pain 
may be entirely absent, or only present under certain conditions, as, for 
instance, during coitus ; or sexual intercourse may be effected with diffi- 
culty or even be impossible. Others will, perhaps, speak of a swelling in 
the abdomen as the leading feature in the case. Some, again, will apply 
for advice because there is no family ; they feel well in every respect. 



DIAGNOSIS IN GYNECOLOGY 



153 



but, having been married for, perhaps, some two or three years, and no 
family resulting, they come for advice on that matter. In many of 
these cases there is no particular illness or discomfort, but it will be 
found that in the vast majority of them some morbid condition is pres- 
ent. The points with reference to which the patient makes complaint, 
and the approximate length of time during which she has experienced 
each symptom, should be noted. These inquiries will probably afford 
some clue to the nature of the case, will indicate the liue any special 
investigation should take, and will serve as a foundation on which to 
construct the diagnosis. The object of the present article, however, is 
not to take up the leading individual symptoms of which the patient 
complains, and then, by following the clues thus obtained, gradually to 
elaborate a diagnosis ; but rather to provide a general systematic form 
of investigation which will be found serviceable in the vast majority of 
gynaecological cases. After these preliminary inquiries the symptoms 
and discomforts of which the patient complains can be sifted and am- 
plified. This method of inquiry provides a very valuable, but often 
neglected quantity of negative evidence. For it often happens that the 
patient comes complaining of something which may be but a trivial 
deviation from health; yet, if her case be gone into systematically 
and carefully, according to the method I propose, important informa- 
tion will be forthcoming which will enable us to find or suspect, even 
before we go into physical examination, that she has some other and 
concomitant disease, either quite independent of the matter of which 
she makes complaint, or entirely subservient to it. 

Having ascertained, then, the main points to which the patient wishes 
to draw attention, and for the relief of which she seeks advice, it is well 
to proceed to ascertain the menstrual and obstetric history of the case. 

The Menstrual History. — At the outset let me emphasise a point to 
which too little attention is given, namely, that in order to obtain first 
from the patient a menstrual history of so complete a character as to 
answer the purposes of investigation, it is necessary to ascertain the 
normal character of the menstruation in the individual. For there are 
among women wide individual differences in respect of this function. In 
order to judge whether any change has taken place in the menstruation 
of any Avoman after its first commencement, the natural character of her 
own menstruation must be determined in the first instance. A certain 
feature of the function which in one woman might be considered an 
abnormal variation may be the usual and natural condition in another. 
And therefore, I repeat, that in each individual case it is necessary to 
ascertain the individual character of the function in order to appreciate 
the importance of any change in it. 

The points in the history of menstruation to which attention should 
be directed are as follows : — 

Tlie Age of Commencement. — Menstruation begins earlier in some 
women, later in others ; it usually begins between the thirteenth and 
fourteenth year. In hot climates it begins at an earlier age ; and it 



154 SYSTEM OF GYNECOLOGY 

varies also in different races. It begins sometimes as early as the 
eighth or ninth year ; sometimes it does not begin till the eighteenth, 
nineteenth, or twentieth. And these variations occur, be it noted, 
altogether apart from disease — such as anaemia. 

The Rhythm of the Flow. — It often happens that after the first period 
or two the patient sees nothing again for some months, perhaps for a 
year or more. After the lapse of some time the flow recommences and 
continues regularly. We are frequently consulted in such cases. A 
girl — say of twelve or thirteen, or a little older — has menstruated 
once, but the flow has not been succeeded by others in the ordinary 
way ; she is consequently brought by her mother to the physician with 
a view to treatment. These cases, as a rule, require no treatment if 
the patient be generally in a healthy condition, and has not exceeded 
the age at which menstruation usually begins. It should be recognised 
that in some individuals it is natural for one flow to show itself, or 
perhaps for two or more to appear, and then for the courses to remain 
in abeyance for some months, often for a year or longer, before the 
rhythmical flow is established. 

Change of residence, especially from the country to London, is often 
attended with cessation of the flow during the stay ; it returns, how^- 
ever, subsequently, and in the meantime the general health is unaffected. 

With most women the flow comes on at intervals of twenty-eight or 
thirty days. In some women, however, it appears at shorter intervals 
— from two to three, or more frequently still, from three to four weeks. 
In others the intervals are prolonged, and the menses recur after an 
interval of five to six weeks, and sometimes longer ; yet these patients, 
so far as one can judge, are in perfect health, and the menstrual func- 
tion is otherwise performed in a proper and natural manner. It will be 
found on inquiry that such peculiarities are natural to the individuals. 

In other patients, again, the menses do not occur regularly, and this 
in patients who have gone on for years without any illness or disturb- 
ance to account for the irregularity. Such persons are never quite reg- 
ular, but if they complain of no illness, irregularity must be looked 
upon as the regular thing for them, and is not necessarily to be regarded 
as pathological. 

The Duration of the Floiv. — Here again considerable variation is 
found within physiological limits. In the majority of women the period 
lasts four or five days; in others it lasts a shorter time, — very often 
only one day, and even in some cases but a few hours. In others the 
flow continues four, five, six, seven, or eight days, or even a little more 
without the presence of any abnormal condition or any interference, so 
far as one can learn, with the general health. In some women it by 
no means infrequently happens that the flow comes on for a day or two, 
then stops for a day or two, and again comes on for two or three days. 
This again, being the natural condition of some individuals, is not by 
any means necessarily pathological. In others it will be found that 
without being pathological the period lasts a variable time; some- 



DIAGNOSIS IN GYNAECOLOGY 155 

times it may last a day or two, at other times rather longer ; occasionally 
it is extended over a week. The duration of the flow in such cases 
depends in great measure on what the patient is doing at the time — 
the more active the patient's life the more extended the periods. 

The Daily Amount. — As a rule, the longer the flow the greater the 
amount of daily loss. But in this, too, there is room for considerable 
variation without exceeding physiological limits. It is difiicult to 
estimate the amount of the daily loss ; but a rough guide may generally 
be obtained from the patient by ascertaining the number of diapers 
which she uses during a period, or during each day of the flow. Some 
patients assert that they never have been able to wear a diaper, as it 
stops the flow. Fortunately such persons do not lose very much. Of 
course, in using this guide to the loss, due allowance mnst be made 
for individual habits of cleanliness ; for while some will only let the 
diapers become partially soiled, others will be less nice. Still the 
number of diapers serves fairly as a rough estimate of the daily loss. 
If a patient tell you that diapers are ■•no good at all," and that she has 
to put on two or three at a time, or uses big cloths or towels, you may 
be quite sure she is losing very freely. Such information is exceedingly 
valuable and suggestive. Some patients will even go further, and say 
that they have to lie np during the period, and put something under 
them to protect the bed-clothes, the loss being so copious. The usual 
average is, perhaps, three or four a day — say, one to two during the 
day, and one at night ; or sometimes three during the day, and one at 
night. When the patient is up and about, the more active she is the 
more she loses, and, generally speaking, the loss is less at night. 
When the amount of the daily loss is great, it is very likely that clots 
will be passed at the same time ; generally speaking, the more copious 
the discharge the greater the liability to the passage of clots. As a rule 
the menstrual fluid does not clot unless it be very free in amount. These 
clots may be quite small ; or they may be of considerable size, as 
big as the thumb, or even larger ; in this case they are due to an 
accumulation of blood in the vagina and its subsequent coagulation. The 
passage of clots is more usual in women who have borne children. With 
the flow there may also be shreds, which are often looked upon as clots 
by the patient ; but they can be distinguished by the fact that shreds 
float out in water. Such a condition is associated with severe pain, and 
is pathological. 

Pain, again, varies in different persons, though short of that which is 
of so severe a character as to come under the head of dysmenorrhoea. 
In some patients at the time of menstruation there is absolutely no pain 
and practically no discomfort: these persons, however, are rather the 
exception than the rule. With women generally, as the flow approaches, 
there is a sense of fulness, congestion, disturbance, and weight in the 
pelvic organs. They become more highly sensitive at that time, and in a 
very considerable number of cases pain is present in greater or less degree ; 
the pain may be at the bottom of the back, in the lower part of the abdo- 



156 SYSTEM OF GYNECOLOGY 



men, or may be referred to one or both ovarian regions. When it is severe 
it may extend beyond these points to the hips, or down the thighs as far as 
the knee ; in other cases it may extend up the abdomen, even to the level 
of the breasts. The amount of the pain may be roughly estimated by 
ascertaining whether the patient has been in the habit of taking any 
remedies for its relief — such as peppermint, ginger, or alcohol in various 
forms, especially in the form of gin ; or, in some cases where medical 
advice has been sought, as laudanum and even hypodermic injections of 
morphia, besides various other remedies. The amount of the pain may 
be gauged also by the patient's answer to the question whether she has 
been able to be up and about her work, whatever it be, at the time 
of the period ; or whether she has had to take to her bed for a longer or 
shorter time, and have hot local applications — such, for example, as a hot 
brick wrapped up in flannel (a useful means of removing pain in some 
cases), hot sand-bags, hot fomentations, stupes, or poultices. 

The time at which the pain begins varies in different individuals. In 
some the pain will begin a day or two before the flow, in others a few 
hours before, while in others it comes on with the flow. It varies also 
in duration: generally speaking, it begins two or three hours before 
the flow and stops after the first day ; in other cases it is continued to 
the end of the second or third day, and may last even to the end of the 
period. As a general rule, however, the pain is at its worst during the 
first few hours of the flow, and begins to diminish as soon as the flow 
has come on freely. 

The Attendant Symptoms. — In some patients, as I have said, there is 
no pain and no discomfort ; in others, severe frontal, occipital, or general 
headache, sick-headache, or vomiting may be present. In other cases 
some disturbance of the bowels, either constipation or diarrhoea, takes 
place at the time of the menses. Most patients, especially during the 
earlier part of the period, require to pass water more frequently than at 
other times ; and with this excessive frequency there is occasionally a 
little pain in micturition. Occasionally patients complain that they have 
fits — hysterical fits — during the flow: these are generally weakly 
patients who are below par, and, being subject to hysteria at other times, 
their tendency to it is increased at the periods. Epileptic attacks also 
seem to be more readily induced during the menstrual flow than at 
other times. 

Leucorrhoea is a symptom rather of the intermenstrual period. In a 
healthy woman there is no discharge, or very little, after the cessation 
of the menses ; but some women have naturally a little discharge of a 
whitish character for a day or two after the flow. In other patients it 
occurs a day or two before the flow ; in others, again, it goes on to a 
greater or less extent during the whole intermenstrual interval. This 
discharge is of an opaque, whitish character. In patients who are re- 
duced in health there is a liability to a certain amount of leucorrhoeal 
discharge apart from any local pelvic trouble. Discharge of a thick 
glairy mucus in large quantity is, however, pathological ; or if the dis- 



DIAGNOSIS IN GYN^COIOGY 157 

charge become yellowish or purulent it passes the physiological bounds. 
Occasionally a peculiar odour may be noticed with a menstrual flow which 
does not pass the physiological limit ; but foetid discharges are invari- 
ably pathological. 

Abnormal Variations. — The date at which the deviation from the 
usual course took place must be ascertained. This deviation may take 
one or more forms. The menses may have come on too frequently, at 
shorter intervals than previously ; they may have come on quite irreg- 
ularly ; the duration may have increased or diminished, or the daily loss 
may have increased or diminished. Pain again, previously absent, may 
have become a prominent feature. In any case we should ascertain pre- 
cisely what the change has been, and the time at which it set in. More- 
over, we should endeavour to ascertain from the patient herself what she 
considers to have been the cause of this change in menstruation. It will 
frequently be found to date from the onset, or from a confinement or sub- 
sequent miscarriage, or it may have begun with some definite illness. 

The menopause usually sets in between the forty -fifth and the fiftieth 
year. Occasionally it occurs earlier, or, on the other hand, it may be 
delayed till after the fiftieth year. Forty-eight is, perhaps, the average 
year of its occurrence. At this time also, as at the beginning of the 
catamenial periods, the menses are often irregular. Menstruation, regu- 
lar up to a certain time, may suddenly cease, and the patient see noth- 
ing more. Occasionally the courses stop for a month or two, perhaps 
longer, then the patient has a period or two at irregular intervals, and 
after this they cease entirely. In other cases the periods gradually get 
less and less for a year or two and then cease ; in others, again, the 
menopause is ushered in by considerable floodings. It is often difficult 
to distinguish these changes associated with the menopause from the 
symptoms of distinct and serious disease. It must always be borne in 
mind, especially in the case of flooding, that women are particularly 
liable to malignant disease at this time. An examination, therefore, 
becomes advisable in order to determine whether the conditions are 
physiological or due to some disease of the organs. 

Both for purposes of future reference and as a guide to the advisa- 
bility of examination by means of the sound, inquiry should be made 
as to the date of the onset of the last period, and the time at which 
the last period ceased. 

It must be remembered with reference to this point, that patients 
frequently think they have menstruated when actual haemorrhage has 
occurred during the course of gestation. Patients will frequently come 
complaining of various troubles, and stating that the last period only 
ceased, let us say, a week ago ; but careful inquiry will elicit the fact 
that for two or three months prior to that time they had seen nothing 
at all, and still closer investigation will show that this so-called last 
'•' period " had not the character of natural menstruation. Whereas, 
perhaps, the patient has never been in the habit of passing clots before, 
these appeared in the discharge on the occasion referred to : or, although 



158 SYSTEM OF GYNECOLOGY 

the periods had generally lasted a week, on this occasion the flow had 
continued for two or three days only, and the amount lost was diif erent. 

The Obstetric History. — I have already dealt with the importance of 
ascertaining the social position of the patient. It is still more impor- 
tant to know what has been her obstetric history — the history of her 
labours and miscarriages, if any ; because a very considerable amount of 
illness which presents itself to the gynaecological physician is the result 
of impregnation and of disease following upon delivery or abortion. 

The first points to ascertain in this connection are the number of 
the children, and the date of the last delivery ; next, whether there 
have been any miscarriages, and if so, when they last occurred. Indeed, 
it is a good plan to go not only as far as this, but to ascertain also with 
regard to the children at what period of pregnancy they were born, 
for they may have been premature ; and as to the miscarriages, at what 
period of gestation they took place : the answers are to be entered in 
their order. All this can readily be recorded in very short compass if 
we put down the labours and miscarriages in the order of their occur- 
rence, and indicate at the same time the period of gestation at which 
each of these events took place by means of figures representing months 
and fractions of months. 

Where premature labour has occurred or miscarriage taken place, it 
is well also to ascertain from the patient whether any particular cause 
could be assigned for the occurrence. A labour may be brought on 
prematurely, or a miscarriage may be induced in various ways, as by a 
fall, a fright, a blow, a strain, over-work, long railway journeys, mental 
exhaustion, and so forth ; and it is well to fortify one's self with this 
information. Therefore we inquire in each case of premature labour 
what cause the patient can assign for the occurrence. Of course, in 
many cases it will be found that no cause, or an obviously inadequate 
cause, is assigned ; and it is in these cases especially that the immediate 
cause may be found in or about the uterus — such, for instance, as the 
presence of a fibroid in the uterus, or chronic metritis and endometritis. 

Apart from the question of prematurity, the character of each 
labour should be ascertained ; whether a long and difficult, or an easy 
one ; and if long or difficult, whether it was aided by instruments. 
Patients .will generally volunteer the information if "the child came 
the wrong way " ; or if, as they say, it was a " cross-birth." The " cross- 
birth " of patients, however, is by no means invariably what the physi- 
cian understands by that name, for a breech presentation is also usually 
dubbed with the name of cross-birth. In order, therefore, to make sure 
that the case was in reality one of cross-birth, it is necessary to inquire 
further whether turning was performed. A breech would probably be 
delivered as such, and no version would be performed ; but if the patient 
states that she was chloroformed, and that the doctor put in his hand 
and turned the child, you conclude that the case was really a cross- 
birth, and not a breech presentation. 

Again, apart from the difficulty of the labours, it is well to ascertain 



DIAGNOSIS IN GYNECOLOGY 159 

whether they have been accompanied by flooding or not ; and whether 
there has been any tear of the soft parts so considerable as to have 
necessitated the introduction of sutures. 

Illness during Pregnancy and after Delivery. — Ascertain also from the 
patient whether her health continued good during pregnancy. Excessive 
sickness, convulsions, oedema, and flooding should be particularly inquired 
after. Patients are generally ready to inform us as to any such illnesses 
as these. With regard to illness after delivery, however, unless ques- 
tioned rather closely, patients are liable to mislead the doctor. It is 
well to ask the patient, in the first place, whether she got on well after 
the child was born; and if in any doubt as to her answer, ask also 
how long she kept to bed. Patients as a rule do not keep their beds 
more than a fortnight after delivery ; if that period has been exceeded 
the chances are that some definite illness occurred during the puerpe- 
rium. It does not necessarily follow, however, that because the patient 
was able to get up after the lapse of ten or fourteen days that she had 
no illness ; for such illness may have been of a transitory kind, or 
she may have got up for a few days while still ill, and had to return 
to bed again for some weeks. 

Illness after delivery is usually of a febrile character. If the patient 
be asked whether she had any fever, she will often reply that she had a 
slight touch of "milk fever." We shall always look with suspicion upon 
such an answer, which probably indicates not mere mastitis, or a local 
trouble giving rise to a certain amount of general febrile symptoms, but 
more often than not it indicates some illness of a septic nature. Such a con- 
dition, in order to prevent alarm on the part of the patient and her friends, 
and sometimes — too often I fear — to shield the reputation of the doctor, is 
put down as milk fever. Mastitis and septic mischief have this in common, 
that both usually begin about the second or third day ; if, however, the 
illness be due to mastitis the breasts as a rule become very hard and tender 
with the influx of milk at that time, and the disturbance usually subsides 
within two or three days when the flow is well established. On the 
other hand, in cases where the breasts have not shown symptoms of local 
disorder (despite the fact that the patient calls the condition "milk fever"), 
but in which tenderness and pain in the abdomen (which you can gener- 
ally infer from the use of hot flannels, hot fomentations, poultices, or 
turpentine stupes) have been prominent symptoms, it may generally be 
concluded that not ^'milk fever," but septic mischief of local origin 
was present. It will be found necessary to cross-question patients rather 
carefully in order to ascertain these facts. If the patient had fever, but 
is unable to give information as to the height of the thermometer, she 
will often be able to afford an indication of the severity of the fever by 
stating whether a rigor or severe shiver occurred at the outset of the 
illness. It may be taken for granted that a rigor at the outset generally 
means fever running up quickly to rather a high point. In long-con- 
tinued febrile conditions repeated rigors generally occur later in the dis- 
ease; and these rigors are generally associated with copious perspirations. 



•i6o SYSTEM OF GYNECOLOGY 

Again, with reference to the general condition of the patient suffering 
from febrile disease, useful additional information may often be obtained 
by inquiring whether she was able to take her food properly while lying- 
up ; or whether she had to be kept on slops, and so forth. Finally, if a 
patient tell you that she can say very little about her condition, as she 
was unconscious for the greater part of the time, you may rest assured 
she was delirious as well as febrile. 

The conditions, apart from febrile illness, which keep a patient in 
bed longer than the usual time, are either general weakness, from some 
pre-existing disease or from haemorrhage before or during labour or 
immediately afterwards, or laceration of the perineum, or some inter- 
current disease, such as pleurisy, rheumatic fever, scarlet fever, or 
measles. 

Previous Illnesses. — It is advisable in the next place to ascertain 
from the patient what previous illnesses she may have had, and whether 
associated with the pelvic organs or not. Many of the troubles com- 
plained of will be found to date from illness occurring at or soon after 
delivery or miscarriage. But it may frequently be found, of course, that 
some particular symptom takes its origin from disease not directly 
associated with the pelvis : for example, any wasting disease, or illness 
of long standing, such as typhoid fever or phthisis, often exerts an im- 
portant influence on the menstrual function. Thus at the beginning of 
a febrile illness there may be severe loss of blood, especially in acute 
diseases — such as typhus fever and small-pox — which are often asso- 
ciated with haemorrhage. Again, when a patient has been laid up for 
a considerable time by prolonged illness — such as typhoid or rheumatic 
fever, the periods are frequently held in abeyance for a long interval, 
and remain so until she regains her strength. 

The History of the Present Illness. — AYe should ascertain first of all 
the date at which the present illness began : this date will form a land- 
mark from which to make more particular inquiries. We should ascer- 
tain also the cause which the patient assigns for her illness, as this will 
often give a clue of considerable value to the nature of her ailment. 

Of the particular symptoms to which attention should be drawn I 
put pain first, because it is one of the most common. Under this head 
are included dysmenorrhoea, that is, pain at and associated with the 
menses ; and dyspareunia, or pain and difficulty in sexual intercourse. 
Pain in association with the functions of the bowel and bladder will be 
dealt with under the head of diseases of these organs. 

Next, inquiries should be directed to ascertain if, in other respects, 
the menstrual function has been naturally performed. Under this head 
are nienorrhagia, metrorrhagia, or haemorrhage during the natural inter- 
vals of the periods ; amenorrhoea, or absence of the periods when they 
ought naturally to have been present ; and, finally, leucorrhoea, a white 
or yellowish discharge occurring between the periods. 

Attention should then be paid to the question of local swelling or 
tumour, whether in the privates or in the abdomen ; then to any inter- 



DIAGNOSIS IN- GYNECOLOGY i6i 

ference with the due discharge of the functions of the bladder and 
bowel; and, finally, to such general symptoms as anaemia, wasting, 
fever, and so forth. It will be necessary for us to consider these mat- 
ters in greater detail, and to enumerate the morbid conditions among 
which these symptoms are likely to be found. 

Pain. — The site of the pain must be noted, whether it be continu- 
ous or spasmodic ; and its character, whether it be sharp and cutting, 
or dull and aching; also whether it be associated with tenderness; 
whether it be relieved by any one of various applications, such as heat, 
cold, pressure, or the adoption of a particular posture, and in wdiat way 
it is apt to become aggravated. 

The causes of pain in the pelvic organs are very various. Inflamma- 
tory and congested conditions stand prominently forward. Under this 
head are included a very considerable number of the diseases to which 
women are specially liable : such are pelvic peritonitis or perimetritis ; 
parametritis, or disease of the cellular tissue of the pelvis ; hsematocele 
— haemorrhage into the pelvic peritoneum setting up pelvic peritonitis ; 
hsematoma — haemorrhage into the pelvic cellular tissue, which sets up 
parametritis and perimetritis in its neighbourhood ; the outcomes of in- 
flammatory mischief, such as pelvic abscess ; inflammatory disease of 
the appendages (tubes and ovaries), such as hydrosalpinx, haematosal- 
pinx, and pyosalpinx ; and inflammation of the uterus itself — metritis. 
Among the congestive conditions I may mention prolapsed or procident 
uterus, and prolapse of the tubes and ovaries. Adhesions, or rather the 
stretching of adhesions left from previous inflammatory mischief due to 
ovarian or tubal disease, are a frequent cause of pain and discomfort ; 
and so, finally, are various tumours in the pelvis, some of which origi- 
nate in the uterus, some in the tubes and ovaries, and often cause press- 
ure and pain, especially if they have become impacted. 

In the acts of micturition and defaecation it is frequently found that 
pain present in the pelvis becomes aggravated, especially if it be the 
result of inflammatory conditions and adhesions. In other cases pain 
occurs only on micturition and defaecation ; these will be considered later 
in association with bladder and intestinal troubles. 

i)?/s29a?*eini?amay occur from various causes. It is frequently associated 
with vaginismus. This condition may be primary or secondary ; that is to 
say, it may have existed from the beginning of attempts at coitus, or it 
may have come on afterwards as the outcome of some other difficulty in 
the act. It may arise from inflamed conditions of the vagina, from what- 
ever cause ; from excessive indulgence in coitus, or from gonorrhoeal in- 
flammation. It is also often found in connection with congenital defects 
and fissures about the vulva, with inflammation of the hymen, or with 
ulcers, specific or otherwise, about the vulva ; or it may frequently be asso- 
ciated with gonorrhoeal warts, or from warts resulting from along-standing 
discharge, not necessarily of a gonorrhoeal nature, but due to irritation — 
such as occurs, for instance, in masturbators. And, lastly, dyspareunia 
and vaginismus may be found in association with urethral caruncle. 

M 



i62 SYSTEM OF GYNECOLOGY 

Apart from these causes directly connected with the orifice of the 
vagina, dyspareunia sometimes occurs in association with some trouble in 
the immediate neighbourhood, such as a rectal fissure or piles. Difficulty 
and pain in coitus are present in some cases of prolapsed uterus ; in these 
cases, if the uterus be outside, sexual intercourse is rendered practically 
impossible, but pain is not necessarily present. With retroverted and 
retroflexed uterus dyspareunia is apt to be present ; and in cases where 
the ovary is prolapsed and congested the pain is often severe. In in- 
flammatory conditions of the pelvis, whether of the pelvic peritoneum 
(perimetritis) or of the cellular tissue (parametritis), and in cases of 
haematocele and hsematoma, which become secondarily associated with 
inflammatory disease, pain in sexual intercourse may result ; or again, 
from adhesions between the tubes, ovaries, uterus, intestine, and other 
parts of the pelvis, which result from long-standing inflammatory mis- 
chief. Cysts in the vaginal wall, though rarely of considerable size, 
occasionally give rise to the difiiculty. Polypi of the uterus passing 
down into the vagina, and flbroid growths becoming impacted in the 
pelvis, will give rise to difficulty and very often to pain in coitus. 

Dysmenorrhoea. — Pain at the periods may have been present from 
the very beginning of menstruation, or have resulted subsequently. 
The division into primary and secondary is useful. The secondary vari- 
ety is very often of an inflammatory character, and dates either from a 
confinement or a miscarriage. In inquiries with reference to dysmenor- 
rhoea we should first ascertain where the pain is situated, whether in the 
abdomen or in the back ; and if in the abdomen, whether it is confined 
to one side or the other, or extends from side to side ; whether it radiates 
down the thighs, or extends for a considerable distance over the abdomen. 
The pain sometimes extends as high as the mammary region. Next, we 
should ascertain when the pain begins, whether before the flow or with 
the flow ; and if before the flow, how long before. Usually it will be 
found that it commences a few hours or a day or two previous to the 
onset of the period; and in cases of severe dysmenorrhoea the pain 
may come on even so long as a week before the period. The duration 
of the pain is variable. In some cases the pain which has begun 
before the period will cease Avhen the flow begins or is freely estab- 
lished. It may cease after the first day, but sometimes in severe 
dysmenorrhoea is continued for two or three days, and occasionally to 
the end of the period ; or again it may even continue after the flow 
has stopped. 

With the view of ascertaining, in the next place, the amount of the 
pain, we should inquire whether the patient has to lie up or not while it 
lasts ; whether she is incapacitated from following her usual occupation. 
Some patients who keep about will tell us that they would lie up if their 
circumstances permitted. Others will tell us that they are always 
obliged to take to bed during the first day or two of the periods ; others, 
again, will say that to do so would be of no use, the pain being so severe 
they cannot keep quiet and have to roll about on the floor. Such facts 



DIAGNOSIS IN GYNECOLOGY 163 

as these will enable us to judge whether the pain be severe or not. In 
cases of less severity, it is possible to judge of the amount of the pain 
by the patient's answer to the question whether any particular treatment 
has been found efficacious in its relief, such as — to take the most popu- 
lar — hot gin and water, hot ginger, local applications, fomentations, hot 
bricks wrapped up in flannel, or hot-water bottles ; and, finally, whether 
they have been under medical treatment during the periods. 

The causes of dysmenorrhcea are to be found either in some general 
condition of ill health, or in some morbid condition of the pelvic organs. 
Let us consider, first, those general conditions which occur apart from the 
uterus and pelvic organs. A very common example of general ill health, 
accompanied by severe menstrual pain, takes the form of a general 
neurosis, the patient suffering from what is termed spasmodic dysmenor- 
rhcea. This form of the disease is always primary in character, begin- 
ning, as a rule, with the first period, and continuing with increasing 
intensity as time goes on. In cases of anaemia and chlorosis, and in 
cases of chronic constipation, dysmenorrhcea of some severity may be 
present without recognisable disease of the uterus or pelvic organs. 
In cases of congestion of the pelvic organs, by whatever cause produced 
— • secondary, it may be, to heart or liver disease — and in cases of inflam- 
mation in the pelvis, dysmenorrhcea may be a prominent symptom. But 
the pain in these cases occurs not, as a rule, during, but between 
the periods. The loss which occurs relieves the congestion, and to some 
extent diminishes the inflammatory condition by depletion, so that 
as soon as the flow is freely established the pain from which the 
patient had previously suffered sometimes ceases, and returns when 
the period has come to an end. 

Certain diseases of the uterus itself are likewise apt to be associated 
with the occurrence of pain at the periods. And first may be mentioned 
the incompletely developed uterus, the uterus being smaller than it 
should be ; very often no bigger than the top of the little finger. With 
it incomplete development of the ovaries is likely to be associated ; 
indeed, these organs may be absent altogether. 

A small congenitally anteflexed uterus is another form of incomplete 
development frequently associated with dysmeuorrhoea. A still more 
common condition takes the form of an elongation of the cervix in its 
vaginal portion, an abnormity known as conical cervix, and usually 
associated with a small orifice or " pin-hole os." 

Fibroma of the uterus is not painful, as a rule, except at the periods. 
During the active congestion which accompanies the early part of the 
periods fibroids often give rise to considerable dysmenorrhcea. 

In cases of displacement of the uterus dysmenorrhcea may become a 
prominent symptom, especially when the uterus becomes retroverted and 
retroflexed, and impacted at the floor of the pelvis between the sacro- 
uterine ligaments. There the congestion in the fundus becomes very 
marked, and severe pain in the early part of the period results. 

Membranous dysmenorrhcea, though rare, is almost invariably asso- 



i64 SYSTEM OF GYNECOLOGY 

ciated with severe pain, during which the patient passes a membrane 
either as a cast of the uterus or in shreds. 

Menorrhagia and Metrorrhagia. — Menorrhagia is an increase in the 
flow at the periods, and takes the form of increased duration of the 
flow, shortening of the interval between the periods, or increased daily 
loss. Metrorrhagia is an irregular flow between the periods. These 
maladies often merge one into the other, so that it may become impos- 
sible to draw any distinct line between them. Of the estimate of quan- 
tity I have already spoken. 

The colour of the flow varies in different cases. When the flow 
is very profuse it has a bright hue. In other cases it is dark in colour, 
the usual colour of the menstrual discharge ; in others, again, it takes on 
a brownish appearance, especially as a free flow is beginning to clear off. 
There may sometimes be a mere show ; or, on the other hand, the loss 
may take the character of a pinkish serous discharge. Occasionally, if 
there be any leucorrhoeal discharge as well, streaks of blood will be found 
in association with it. 

General Causes of Haemorrhage. — In a certain number of cases of 
anaemia and chlorosis, in contradistinction to the usual condition of 
amenorrhoea, menorrhagia appears. This is the case rather in the severer 
forms of the disease ; indeed, the loss tends to aggravate the disorder. 
In congestive conditions of the heart and liver menorrhagia is apt to 
be present, and, of course, metrorrhagia too ; for owing to the obstruction 
of the circulation an excessive flow is apt to occur not only at the 
periods, but also between them. This loss may be compared with the 
escape from a safety-valve, and should not be injudiciously checked. In 
some cases of acute specific disease, and especially in those associated 
with hsemorrliagic tendency — such as typhus fever, scarlet fever, small- 
pox, and, to a less extent, measles — menorrhagia is apt to set in at the 
beginning of the fever. Sometimes it becomes marked and requires 
particular treatment. In some blood diseases, again, such as purpura 
and haemophilia, an increased flow at the periods is apt to occur. 

Local Causes of Haemorrhage. — Erom these general causes I pass next 
to certain conditions in the pelvis outside the uterus. In inflammatory 
conditions in the pelvis — such as parametritis and perimetritis — menor- 
rhagia and metrorrhagia sometimes occur. These cases almost come into 
the same category as those in which the heart and liver are diseased ; 
for in many of them, at any rate, the vessels become involved, the veins 
become plugged, and so the return of the blood to the heart is interfered 
with. The loss in such cases, therefore, unless it be excessive, has a 
beneficial tendency by depleting, and thus relieving the inflammatory 
condition. 

In pelvic haematocele and pelvic haematoma bleeding is apt to take 
place. The usual history in such cases is that, either as the result of some 
excessive work undertaken at the period, or of a chill caught after the flow 
has begun, the discharge suddenly ceased, but reappeared and thereafter 
continued for a longer time than it should do, perhaps for a fortnight. 



DIAGNOSIS IN GYNAECOLOGY 



In some cases of ovarian congestion and ovaritis menorrhagia and 
metrorrhagia are liable to ensue. Especially is this likely to occur as 
the result of too frequent sexual intercourse soon after marriage. In 
ovarian disease proper — such as ovarian cystoma — amenorrhoea is the 
rule ; but in a certain number of cases menorrhagia and metrorrhagia 
take its place. The same remark also applies to cases of tubal disease, 

— hydrosalpinx, hsematosalpinx, and pyosalpinx; in these, though 
amenorrhoea more frequently occurs, menorrhagia and sometimes 
metrorrhagia are occasionally present. 

The abnormal conditions of the uterus itself, which give rise to 
haemorrhage, may be conveniently divided into those found in the unim- 
pregnated and those occurring in connection with child-bearing, whether 
during pregnancy or during the puerperium. 

In cases of metritis, with disease of the lining membrane of the uterus 

— a state to which various names, such as fungous and villous endome- 
tritis, have been given — haemorrhage is an almost constant symptom: 
there is excessive flow at the periods, and very often a loss also between 
the periods ; the periods come on too frequently, last too long, and the 
daily loss is more than natural. 

In cases of mucous polypi of the cervix, again, hsemorrhage is by no 
means uncommon ; and with this I ought to mention a condition ante- 
cedent to it, namely, the thickening of the mucous membrane of the cervix, 
with proliferation of the gland tissue, which often extends to the vaginal 
portion, and produces what is known as an adenomatous erosion. This 
condition gives rise not only to excessive haemorrhage during the periods, 
but also very frequently to haemorrhage during the intermenstrual time. 
It may be particularly noted that in this case the haemorrhage — a metror- 
rhagia — is apt to follow sexual intercourse. 

Fibroids or myomas in the uterus are frequently, but not invariably 
associated with haemorrhage. Fibroids projecting on the peritoneal 
surface — that is to say. subperitoneal fibroids — do not in themselves 
cause haemorrhage ; fibroids in the wall of the uterus, unless the}^ 
encroach on the cavity and cause it to enlarge, do not give rise to 
haemorrhage ; but haemorrhage may be caused by fibroids projecting into 
the uterine cavity, that is to say, by submucous fibroids ; although here 
again bleeding is not an invariable concomitant. Fibroids, however, 
when they become polypoid, almost invariably produce haemorrhage. 
It must be remembered that fibroids are frequently multiple; and that 
the symptoms may be due, not to a subperitoneal fibroid even of consider- 
able size, but to a smaller mass not always easily recognised beneath 
the mucous membrane. The haemorrhage which occurs in association 
with fibroids is generally menorrhagic in character, although it occasion- 
alty occurs in the intervals between the courses, and is often very pro- 
fuse. It is probably due directly to an unhealthy condition of the uterine 
mucosa induced by the presence of the fibroid mass. 

Malignant disease of the uterus, which generally affects the cervix, 
is a potent cause of haemorrhage. Especially is it one of the causes of 



i66 SYSTEM OF GYNECOLOGY 

hsemorrhage occurring at the climacteric. The haemorrhage may be 
menorrhagic, but it is more frequently metrorrhagic in character. 
From the cervix the malignant disease may spread to the body of the 
uterus. Primary cancer of the body of the uterus is also associated 
with haemorrhage, but it is a comparatively rare condition, and the 
haemorrhage when it occurs is not, as a rule, very severe. It usually 
takes the character of a watery discharge with a pinkish tinge rather 
than of a severe flow of blood ; though in certain cases even of primary 
cancer of the body severe floodings may take place. In sarcoma of the 
body of the uterus haemorrhage is apt to occur and to constitute a promi- 
nent symptom. 

Senile endometritis is another condition occasionally met with, giving 
rise to haemorrhage after the menopause. The distinction between senile 
endometritis and cancer of the body of the uterus can, as a rule, only be 
determined by exploration of the cavity of the organ. 

Special Causes of Haemorrhage during Pregnancy and after Delivery. 
— It may be noted that occasionally the catamenia persist after impreg- 
nation has taken place ; the periods being sometimes continued during 
the first, second, and third months, rarely later than that. It is often 
difficult in any individual case to say whether a discharge of this kind 
is really a menstrual period ; but usually, if it preserve the same char- 
acter as a period and come on regularly, it may be looked upon as such. 
When, however, from some morbid condition, bleeding occurs during 
gestation, the loss is specially apt to take place just as the monthly 
cycles come round; consequently an impression of regular periods may 
be produced in the patient's mind. 

Haemorrhage in association with gestation may be symptomatic of 
threatened abortion, of bloody, fleshy, or vesicular mole, or of ectopic 
gestation ; and, during the last two months of pregnancy, of accidental 
haemorrhage or of placenta praevia. It will suffice merely to mention 
these matters here. 

It may be useful to bear in mind that the other causes of haemorrhage 
occurring during pregnancy — haemorrhage, that is, from the uterus — are 
generally associated either with cancer of the cervix ; or with adenoma of 
the cervix, commonly called erosion ; or sometimes with mucous polypi. 

Haemorrhages occurring shortly after delivery do not fall within the 
scope of this volume. Haemorrhage setting in after the patient has left 
her bed and the lochia have ceased may depend on one of several 
conditions. It frequently occurs in cases of subinvolution; often in 
association with inflammatory disease, or with the retention of some 
portion either of placenta, membrane, or blood-clot within the uterus ; or 
with the presence of a fibroid growth, either in the wall or beneath the 
submucous tissue of the uterus, or of a polypus. Moreover, the 
mucous membrane may take on an irregular, villous, or fungous char- 
acter, associated in many cases with very considerable haemorrhage. 

More or less sharp haemorrhage will occur in some cases when the 
patient begins to get up ; and on examination it will be found that the 



DIAGNOSIS IN GYNECOLOGY 167 

uterus is prolapsed, retroverted, and larger than it should be from conges- 
tion, and sometimes firmly impacted in the pelvis. In cases of inversion 
of the uterus a considerable loss often takes place, with leucorrhoeal 
discharge in the intervals. 

Slight haemorrhage after delivery may occur from incompletely healed 
laceration of the cervix, or from erosion. Cancerous growths of the 
cervix must also be borne in mind as a possible cause of haemorrhage. 

Amenorrhoea. — Daring pregnancy, as well as during suckling, amen- 
orrhoea is the rule. But, as already stated, the courses sometimes persist 
during the early months of pregnancy, and even later. Many women, 
too, especially those of rather florid temperament, will continue to have 
the periods regularly during suckling, and that even from a month after 
delivery. It is necessary to bear this feature in mind, because patients 
are apt to be misled in consequence, and even when far advanced in 
pregnancy will persist that no impregnation can have taken place. A 
general impression also prevails that suckling prevents impregnation. To 
a certain extent this is true, but by no means invariably. Women who 
have been suckling regularly may be found far advanced in pregnancy, 
having one child at the breast while carrying another. 

When the menopause is artificially induced, as by the removal of the 
ovaries, for fibroid disease of the uterus or other such reason, amenorrhoea 
as a rule results. Occasionally the patient will have one period after- 
wards, sometimes two or three. In cases, however, where the periods 
continue regularly it is doubtful whether the whole of both ovaries has 
been removed ; removal of one ovary does not stop the flow. In some 
cases after complete removal of both ovaries an irregular loss occurs, 
resulting from concomitant disease of the uterus itself, such as the 
presence of a small polypus, mucous or otherwise, in the cervix or body; 
or disease of the lining membrane of the uterus. 

Among the general causes of amenorrhoea anaemia stands first in 
point of frequency. 

Amenorrhoea is also apt to result from any cause of malnutrition, 
particularly acute illness or chronic wasting disease : it may be found, for 
example, after rheumatic fever, during and after typhoid, in phthisis and 
Bright's disease, and so forth. 

A chill taken during menstruation will sometimes stop the periods 
without producing any discoverable lesion of the pelvic organs, but often 
inflammation and other disorder is at the same time induced. 

In cases of chronic inflammation of the ovaries and tubes, in ovarian 
cystoma, in hydrosalpinx, hsematosalpinx, and pyosalpinx, amenorrhoea 
is sometimes though not invariably present. In some cases the regularity 
of the periods may not be interfered with, and in others menorrhagia 
takes place. 

In rudimentary conditions of the ovaries and uterus primary 
amenorrhoea is frequently present, and, if not absolute, it will usually 
happen that the periods occur at considerable intervals — five or six weeks, 
perhaps two or three months intervening — and the loss is very slight, a 



SYSTEM OF GYNMCOLOGY 



mere show on each occasion. But here again amenorrhoea is by no 
means invariable. I have known cases of small uterus and ill-developed 
ovaries with menorrhagia. 

LeucorrhoRa. — In making inquiries with regard to leucorrhoea we 
should ascertain, first of all, the character of the discharge. It may be 
white or colourless, opaque or glairy ; that is, either like milk or like the 
white of Qg^. The natural discharge from the cervix is glairy and mucoid, 
becoming opaque when it passes into the vagina. On the other hand, in 
disease the discharge may be of a yellowish or creamy colour ; or it may 
be greenish, or brown and mixed with blood. With a view to ascertain 
the extent of the discharge the patient may be asked whether it is such 
as to require a diaper. The answer will generally afford some means of 
ascertaining its amount. Then we should inquire when it occurs — whether 
it persists during the whole intermenstrual period, or comes on just before 
or just after the flow — and when it is of greatest intensity. As a rule 
leucorrhoeal discharges are most marked just before or just after the 
menstrual flow. 

The causes of leucorrhoea are general weakness, ansemia, wasting 
diseases, and worms. Thread-worms in children are especially apt to be 
associated with considerable leucorrhoeal discharge. Under these circum- 
stances the mother frequently brings the child to the doctor, imagining, 
perhaps, that she has been tampered with. We should look out for worms 
in such cases, or for the vulvitis which in children follows such diseases 
as measles, scarlatina, whooping-cough, chicken-pox, and the like. 

Leucorrhoea may be the result of vaginitis, arising either from the 
presence of foreign bodies in the vagina, from some irritation of the 
vagina, as in cases of masturbation, or from the presence of ill-fitting 
pessaries or pessaries that have been worn for a considerable time. With 
vascular caruncle of the urethra there may sometimes be a little 
leucorrhoeal discharge. 

Gonorrhoea is a potent cause of leucorrhoeal discharge, often in its 
worst form ; but even in these cases the discharge is not necessarily 
profuse. 

Soft chancres about the vulva, again, are frequently associated with 
a certain amount of leucorrhoeal discharge. Tears about the vulva, too, 
such as occur after operations or after delivery, if they fail to heal prop- 
erly, may give rise to a leucorrhoeal discharge. 

Erosions of the cervix, whether merely catarrhal or adenomatous, are 
generally accompanied by a discharge which, as it pours away from the 
cervix, is glairy ; but it becomes opaque on reaching the vagina unless the 
quantity be great. The discharge in some of these cases in very profuse. 

Eversion of the cervix, generally the result of a bilateral laceration 
of the cervix occurring during delivery, is attended by leucorrhoea. 

Leucorrhoea is also to be found in cases of mucous polypi of the 
cervix, in cases of cervical catarrh, in cases of subinvolution of the 
uterus occurring after delivery or miscarriage, in cases of senile cor- 
poreal endometritis, in disease of the uterine mucosa, whether associated 



DIAGNOSIS IN GYNECOLOGY 169 

with submucous fibroids and polypi of the uterus or not, in cases of 
cancer of the uterus, in cases of chronic inversion of the uterus, and, 
finally, in some cases of pyosalpinx and pelvic abscess, or suppurating 
cyst in the pelvis, when the discharge finds its way by perforation 
through the uterus or, more frequently, through the vagina. In all 
such cases the leucorrhoeal discharge is liable to alternate with unusual 
losses of blood. 

Foetor of the discharges (which necessarily means saprsemic decom- 
position) may be met with in cases of threatened miscarriage and of 
incomplete abortion ; in cases of subinvolution associated with retained 
products of gestation ; in cases of severe inflammatory mischief, such as 
occurs in gonorrhoea, and particularly when an abscess has opened into 
the canal; incases of cancer; incases of senile endometritis ; and in 
some cases of submucous fibroids and polypi in which the tumour has 
sloughed. The discharge, however, may take on an offensive odour 
under other conditions, — as, for example, with mere rents about the 
vulva, such as occur after delivery, — and in some cases of cervical 
erosion and eversion. 

Local Swellings or Tumours. — We should ascertain from the patient 
if she has noticed any swelling either in the abdomen or privates ; when 
the swelling first appeared, and whether it be persistent or variable in char- 
acter. We should inquire also the site where it was first noticed, and the 
direction in which it has grown. In order to ascertain from the patient 
whether any considerable enlargement of the abdomen has really taken 
place, it is well to ask whether she has had to let out her clothes. 
Uterine enlargements commence at or near the middle line ; ovarian 
tumours are usually noticed first at one side or the other, and only after 
a time, as increase takes place, do they extend upwards and towards the 
middle line. Distensions of the tubes and inflammatory effusions are 
usually found near the groins, and thence extend into the iliac fossae. 

Among unilateral swellings about the vulva may be mentioned 
abscess, cyst, varicose enlargement, inflammatory induration of the 
labium, and possibly hernia. Protrusions in the middle line are 
commonly urethral caruncle, cystocele, rectocele, or prolapsed and pro- 
cident uterus. 

The various tumours met with in the abdomen and pelvis will be 
enumerated later in dealing with the abdominal and vaginal examination 
of the patient. 

Urinary Symptoms. — We should note the character of the pain, if 
present, and the time at which it occurs — whether during micturition, 
previous to micturition, or following micturition. We should note also 
the frequency of micturition, and whether it takes place most frequently 
at night so as to disturb the patient's rest, or during the day when she 
is up and about ; or if, on the other hand, there be difficulty in getting 
the water to pass, or such inability as to necessitate the use of the 
catheter. Or, again, the water may constantly run away ; or be passed 
involuntarily on coughing or straining. 



I70 SYSTEM OF GYNECOLOGY 

The character of the urine may be partly learned from the patient, 
and will probably also be tested. Pus, blood, or mucus from the 
vagina may be found mixed with it, and, in order to obtain a sample 
uncontaminated, it may be advisable to pass the catheter. Many 
general diseases — such as diabetes, insipidus, and mellitus ; hysteria ; 
nocturnal incontinence — may give rise to one or other of the foregoing 
symptoms ; or affections of the urinary organs not a part of the special 
diseases of women — nephritis, for instance, whether acute or chronic ; 
calculus either in the kidney, ureter, or bladder; pyelitis; cystitis; or 
displaced kidney — may interfere with the urinary function. 

Associated with disturbance of micturition may be mentioned cysto- 
cele with or without prolapse of the uterus ; until the swelling be pressed 
up this frequently causes difficulty and delay in passing water. In 
cases of vesico-urinary and vagino-urinary fistulas, constant or nearly 
constant dribbling away of the urine takes place. Vascular caruncle 
frequently gives rise to pain in passing the water. In vulvitis, such as 
sometimes affects weakly children ; in vaginitis, from whatever cause 

— such as foreign bodies, ill-fitting pessaries, and so forth, or resulting 
from general weakness ; and in cases of gonorrhoea, the urethra is often 
implicated ; and pain in passing water is complained of as well as difficulty 
in getting the water to pass : occasionally there is retention. 

In cases of polypi from the uterus coming down into the vagina, 
and of various tumours (especially when impacted in the pelvis), such as 
fibroids, ovarian tumours, parovarian tumours, dermoid tumours of the 
ovary, tubal distensions, hydrosalpinx, haematosalpinx, and pyosalpinx, 
ectopic gestations, and retroverted gravid uterus, micturition may be 
interfered with ; and incontinence, excessive frequency of micturition, 
pain in passing water, or retention may take place. The same may 
occur in advanced cases of cancer, of sarcoma of the uterus, and of in- 
flammatory conditions in the pelvis, such as perimetritis, and parametritis, 
hsematocele, hsematoma, and pelvic abscess. Finally, unusual frequency 
of micturition may be reckoned as one of tlie earliest signs of pregnancy. 

Intestinal Symptoms. — We should ascertain the frequency with which 
the bowels are relieved, and if defsecation be painful, difficult, or asso- 
ciated with tenesmus. If constipation be a prominent feature the 
effects of remedies often afford us some information. The presence of 
blood, mucus, or pus in the stools should be noted. We should next note 
the condition of the tongue, and inquire as to the appetite and digestion 

— whether nausea or vomiting be present, and if so, the time at which 
they occur, and the character of the vomit ; facts which may have an 
important bearing on the question of gestation. 

It may be remarked that these intestinal troubles, like the urinary, are 
not by any means necessarily associated with disease in the pelvis, but 
more often result from general disease, such as chronic constipation ; or 
from disease of the lower bowel, such as haemorrhoids, stricture, malignant 
disease, and fistula in ano. But among other causes may be instanced 
recto-vaginal fistula, rectocele with prolapse of the posterior vaginal wall, 



DIAGNOSIS IN GYNECOLOGY 171 

prolapse of the uterus and procident uterus, tumours impacted in the pel- 
vis, cancer, sarcoma, and fibroids of the uterus. Again in inflammatory 
swellings, such as perimetritis and parametritis, hsematoma, hsematocele, 
and pelvic abscess, the inflammatory process often involves the mucous 
membrane of the bowel, and sometimes leads to the passage of blood and 
mucus. Pain and difficulty in defsecation are apt to be present when the 
ovaries and tubes are prolapsed, and the uterus retroflexed or retroverted ; 
for, if the bowels become constipated, the attempts at defsecation force 
the fseces down above the misplaced mass, which may act as a sort of 
ball-valve on the rectum, and increase the difficulty. 

General Symptoms. — Anaemia, wasting, fever, and so forth, will 
generally come to light with the other and more special symptoms of 
which the patient has already complained. 

Previous Treatment. — Finally, we must ascertain and note what 
previous treatment, if any, has been adopted, how long it has been 
carried out, and with what result. We should note particularly 
whether the patient had been confined to bed, and for what length of 
time ; and what local measures, if any, have been adopted, either in 
the form of applications, such as douches, tampons, pessaries, or of 
operative procedures. 

The physical examinatiox of the patient. — In conducting the 
physical examination of the patient attention will first be directed to 
the abdomen ; afterwards to the internal examination. 

Examination of the Abdomen. — We should note first the size and 
shape of the abdomen. If it be enlarged measurements must be taken. 
These are from the umbilicus to the xiphi-sternal articulation ; from the 
umbilicus to the top of the symphysis ; from the umbilicus to the ante- 
rior superior spines, right and left ; the girth at the umbilicus, and in 
great enlargements the greatest girth. 

In the next place the umbilicus is to be observed, whether it be 
protruded or depressed: it protrudes when there is free fluid in the 
abdomen and in cases of umbilical hernia ; it is unusually depressed 
when there is much fat on the abdominal wall. 

A note also sliould be made of the condition of the linea alba, the 
marked pigmentation of which, at any rate in the lower part, is often 
an indication of pregnancy. 

The existence of strise or skin cracks on the external surface of the 
abdomen is to be noted; their number, their size, their colour, their 
position, and the direction in which they run. Skin cracks are an 
indication that the abdomen is or has been distended ; not necessarily by 
pregnancy, though that is the most common cause : ascites and other like 
distensions will produce them. The colour of these cracks will vary with 
the lapse of time since the distension occurred ; fresh skin cracks are 
usually pinkish in colour ; old ones are whitish, or, if they have become 
redistended, acquire a bluish tinge. Their number and size will vary 
not only according to the amount of the distension, but also in individ- 
nal cases. Some women pass through full term pregnancies, and have 



172 SYSTEM OF GYNAECOLOGY 

not a single stria left to tell the story ; in others the abdomen may be 
scored by striae before the mid-term of pregnancy is reached. 

The thickness of the abdominal walls varies in the main with the 
amount of their adipose tissue. In women who have not had children 
they are often extremely rigid, especially in neurotic subjects ; whereas 
in women in whom the abdomen has been distended, or who are generally 
lax of tissue, the walls may be so exceedingly thin and loose that the hand 
may sink deeply enough on the abdomen between the separated recti for 
the promontory of the sacrum to be felt ; and, perhaps, the brim of the 
pelvis may be mapped out through the anterior abdominal wall. Any 
hernial protrusion on the abdominal wall, whether at the umbilicus or in 
the groin, should be duly noted ; and likewise any considerable tender- 
ness or resistance in t'he abdominal walls. Neurotic patients under 
manipulation are very apt to contract the walls of the abdomen ; but in 
these patients the resistance is general over the abdomen, and not limited 
to the lower part or to one side, as is usual in pelvic disease. 

Abdominal Enlargements. — The main causes of enlargement, apart 
from distinct tumours in the abdomen, are the following : — 

i. General obesity, a thick adipose condition of the abdominal wall, 
associated with a large deposit of fat in the omentum and other parts of 
the abdomen beneath the peritoneum. This deposit of fat often occurs 
about the menopause. The abdominal wall may be increased to some 
four or five inches in thickness, a state of matters which very much 
interferes with any examination of the deeper structures of the abdomen. 

ii. Flatulence often produces general enlargement of the abdomen, 
and likewise interferes with examination. It is associated with a tym- 
panitic note on percussion. In some women enormous distension is thus 
produced. In young girls, also, considerable distension of a more local- 
ised nature often gives rise to the impression of pregnancy ; but here, 
again, the tympanitic note on percussion is distinctive enough : under 
chloroform such swellings disappear. 

iii. General enlargement of the abdomen, due to fluid accumulation, 
is accompanied by dulness on percussion, as in ascites associated with 
disease of the heart or liver. The effusion may be serous, fibrinous, 
purulent, or heemorrhagic. 

iv. Occasionally a distinct tumour of the abdominal wall itself may 
be met with. I have seen a lipoma which, in its position at any rate, 
very closely simulated a small ovarian tumour — for which, indeed, it 
had been mistaken ; but careful examination showed that it was situ- 
ated in the abdominal wall and not beneath it. 

Intra-abdominal Tumours. — If a tumour be found in the abdomen 
it is important to learn when the swelling was first noticed, and whether 
attention was drawn to it by pain or by the increase of the abdomen. 
We must also ascertain at what point it was first observed, whether in 
the upper or lower part of the abdomen, or to one side or the other ; 
the direction of its subsequent growth; its rate of progress, and 
whether its growth has been steady or variable in rate. 



DJ A GNOSIS IN GYNECOLOGY 



The tumour may appear to be rising out of the pelvis in the middle 
line, or to one side of it ; to spring from the lumbar region, or from the 
upper part of the abdomen under the ribs. The longest and shortest 
measurement of the tumour must be noted; its shape and outline, 
whether regular or irregular, or ill-defined ; its consistence, whether it 
be hard, as is usual in fibroids, or soft, as are most ovarian swellings ; 
whether fluctuation be present or not, and if present, whether the fluid 
thrill is conducted equally in all directions. The mobility of the tumour 
should be determined, and also the point where it appears to be attached. 
Occasionally a tumour may be fairly movable, but limited by adhesions 
in one or more directions — conditions which can readily be estimated 
by palpation through a thin and lax abdominal wall. In endeavour- 
ing to ascertain the mobility of the tumour one may notice a distinct 
crepitant feeling transmitted to the hand, which usually indicates that 
some inflammatory mischief has produced a considerable roughness of 
the tumour. In some cases, again, under favourable conditions of the 
abdominal wall, a pedicle may be felt. The extent of the area of dulness 
on superficial or deep percussion may or may not correspond with the 
size of the tumour. The stethoscope will enable us to ascertain whether 
there be any sounds about the tumour. Apart from the sounds of preg- 
nancy, in some cases of fibroid tumour a sound resembling the uterine 
bruit of gestation may be heard ; or if the surface of the tumour has 
been roughened by inflammation, friction sounds may be distinguished : 
in many cases adventitious sounds are conducted from the aorta or 
intestine. 

Pressure on the main venous trunks gives rise, in some cases, to 
engorgement of the veins running over the abdominal wall ; in others 
to varicose veins about the vulva, thighs, and legs, and to oedema of the 
lower extremities. 

In exceptional cases, as a means of diagnosis, an exploratory punct- 
ure of the tumour may be allowed, and a microscopical examination of 
the fluid made in order to ascertain the nature of the swelling ; finally, 
exploratory opening of the abdomen may sometimes be called for to 
clear up an obscure case. 

In dealing with tumours in the abdomen, it is at the outset advisable 
to eliminate the possibility of pregnancy. Before proceeding, therefore, 
to a differential diagnosis of the intra-abdominal tumours it will be 
advantageous to briefly consider the indications of gestation. 

Diagnosis of Pregnancy. — The shape of the uterus is to be noted, 
whether there be any marked obliquity or not ; this, if present, is 
usually directed to the right side of the abdomen. On palpation the 
tumour may present the characters of a gestation, that is to say, of fluid 
containing a solid (the foetus) ; with easy conditions of the abdominal 
wall as regards thickness and resistance, it may be possible to map out 
the position of the back, of the small parts, and of the head of the foetus ; 
and to feel the foetal movements. In some cases a thrill may be felt, 
though this is by no means common. Contractions of the uterine 



174 SYSTEM OF GYNECOLOGY 

muscle can usually be induced, anid are an important diagnostic sign, 
but they occur also in fibroid tumours. At the sixth month of preg- 
nancy the fundus of the uterus reaches to about the level of the navel ; 
at the fifth month it is about half-way between the navel and the pubes ; 
at the fourth month it can be distinctly felt above the pubes ; before 
that period it is not easily felt above the brim. At the seventh month 
the fundus arrives about half-way between the navel and the ensiform 
cartilage ; at the eighth month it rises to the level of the xiphi-sternal 
articulation, and during the last month, as the foetal head comes down 
in the pelvis, it sinks a little again in the abdomen. But it must be 
remembered that the size may be interfered Avith by various circum- 
stances. In cases of multiple pregnancy — twins or triplets — the uterus 
at any given stage is larger than in a normal gestation : this is also the 
case when the liquor amnii is excessive, and in hydatidiform mole. The 
w^omb is smaller than usual when the foetus is abnormally small ; when 
the foetus dies, prematurely or not, or is interfered with in its develop- 
ment. When the contents of the uterus have been converted into a 
mole the organ may remain for a long time almost stationary in size. 
If, on auscultating the abdomen, the foetal heart is heard with certainty, 
the question of gestation is at once settled. But inability to hear the 
heart sounds does not necessarily contra-indicate pregnancy, for this sign 
is naturally absent till four and a half months of development have been 
attained : and, even later, it cannot always be heard even though the 
foetus be alive. By observing the rhythm of the foetal heart, and at the 
same time counting the rate of the maternal pulse, the possible error of 
mistaking conducted sounds from the mother's arteries may be avoided. 
While listening to the foetal heart, it is often possible, with the hand 
on the other side of the abdomen, to feel the foetal movements quite 
distinctly ; and also, perhaps, contractions of the uterine muscle, induced 
by the pressure of the stethoscope : both of these signs are valuable indi- 
cations of pregnancy. In some cases, though not often, one may light 
upon an umbilical bruit, a sound produced by the pressure of the steth- 
oscope on the umbilical cord ; it is synchronous with the foetal pulse, 
not with the maternal. Much more frequently the uterine bruit is 
heard, a sound which is said to be produced in the large sinuses of the 
uterus ; this bruit is synchronous with the maternal pulse. The uterine 
bruit varies much in different cases, and in its characters ; it may vary 
even in the same case at different times. Sometimes it is a soft mur- 
mur ; sometimes its note is almost hard and shrill ; it varies from time 
to time in intensity and pitch, and in the position in which it is heard. 
It may be taken as diagnostic of the uterine character of the tumour, 
but not necessarily of pregnancy ; for it is sometimes heard in cases of 
uterine fibroid. 

If the uterus is regularly enlarged, if no indication of disease be 
present, and if the uterus corresponds in size with what might be ex- 
pected, the diagnosis of gestation is usually warranted, even in the early 
months before the advent of any certain indication. But when compli- 



DIAGNOSIS IN GYNMCOLOGY 175 

cations are present; or the history is misleading, as in ectopic ges- 
tation ; or unreliable, as when the patient has reason to conceal the 
event, it is well to withhold an opinion until some certain sign appears. 
In doubtful cases some evidence may also be derived from the breasts. 
The breasts usually become distended and enlarged before the mid-period 
of pregnancy is reached ; the nipples and the areolae surrounding them 
become more prominent ; the follicles which they contain stand up from 
the surface ; and the pigmentation, especially in dark-complexioned sub- 
jects, becomes augmented, and spreads beyond the true areolae so as to 
form a darkened area, with small spots upon it devoid of pigment : this 
is exceedingly characteristic of pregnancy, though not absolutely diag- 
nostic of it, for similar pigmentation is occasionally observed in cases 
of fibroid tumours of the uterus and of ovarian cystoma. 

Further, fluid may exude from the nipple on pressing the breasts. 
Though the pigmentation and secretion afford presumptive evidence of 
pregnancy, it must be borne in mind that these signs are of little or no 
value after the first pregnancy, for they persist after delivery. 

The striae of distension on the breasts rarely occur except as the 
result of engorgement during lactation. 

It is rare for an abscess to form in the breasts except after child-birth 
or miscarriage, so that the mark left by an abscess is also fairly 
presumptive evidence of past gestation. 

Before passing on to speak of the various tumours found in the 
abdomen it will be advisable to anticipate somewhat, by referring also 
to the internal examination in cases of pregnancy. If the patient be 
pregnant, the following points may be noted in making the internal 
examination : — 

The cervical canal is often patulous during the fifth, sixth, and 
seventh, and even during the eighth month of gestation ; but it closes as 
the time of delivery approaches, and before the dilatation proper to 
labour begins. Its size, its dilatability, and its length should be noted. 
The cervix becomes thickened and softened during gestation, and during 
the last three months of pregnancy it apparently becomes drawn up out 
of the vagina. 

If the cervix is sufficiently dilated, it may be possible to feel the 
membranes within it, or possibly the placenta in cases of placenta praevia, 
or blood-clot if haemorrhage have occurred. Blood-clot may be distin- 
guished from placenta or membrane by its vanishing under pressure of 
the finger and thumb ; membrane or placental tissue will not entirely give 
way, or if doubt still remain the mass may be removed for examination. 

Through the cervix it may be possible to distinguish the presenting 
part of a foetus ; but more frequently its presence may be ascertained 
by pressure through the anterior vaginal wall in front of the cervix. 
During the mid-period of gestation ballotement can be practised, and, if 
obtained, it forms a valuable additional indication of pregnancy. 

Abdominal tumours, other than pj-egnancy, may be met with in the 
abdomen. Tumours of the abdomen beginning above and coming 



176 SYSTEM OF GYNAECOLOGY 

down from under tlie ribs, though they may be met with among 
gynaecological patients, do not properly fall within that category, 
except as a matter of coincidence. Of such, for instance, are enlarge- 
ments of the liver and gall-bladder, of the spleen, and of the stomach. 
Other tumours of the abdomen take their origin very variously; 
as, for instance, cancer of the bowel, feecal accumulations, localised 
peritonitis with effusion, adhesions the result of peritonitis (which 
I mention here because the impression of a very distinct tumour 
is often conveyed by such adhesions), omental cysts, hydatids, and 
tumours of retroperitoneal origin. Tumours of the kidney beginning in 
one or other lumbar region frequently find their way to the brim of the 
pelvis; or, at any rate, into the iliac fossa. An abnormally mobile or 
wandering kidney is frequently observed among gynaecological patients, 
for the simple reason that this condition, which is more common on the 
right than on the left side, is usually associated with a general laxity 
of the patient's parts, and with displacement of the uterus or of the 
ovaries. 

Tumours beginning below may be uterine, tubal, ovarian, or para- 
metric in origin. A full bladder should invariably be reduced, in any 
doubtful case of abdominal tumour, by passing a catheter. It is not 
sufficient to rest satisfied with the patient's statement that urine has been 
passed recently ; because, when the bladder is full, though micturition be 
frequent, the amount passed is small, and often consists merely of overflow. 

Of the various uterine enlargements some preserve the natural 
contour of the uterus, others are irregular in shape. Among the 
regular enlargements may be reckoned gestation ; hydatidif orm, blood, 
and fleshy mole ; an abnormal enlargement of the uterus remaining 
after delivery, under the general term of subinvolution ; metritis ; pyo- 
metra, and haematometra. Among the irregular enlargements may be 
instanced fibroid tumours of the uterus — subperitoneal, interstitial, sub- 
mucous, or polypoid ; and malignant disease, cancer, and sarcoma. 

Enlargements of the tubes, so great as to cause abdominal swelling, 
may be due to tubal gestation, which often ruptures and spreads into the 
broad ligament, or into the abdominal cavity ; hydrosalpinx ; pyosalpinx, 
whether gonorrhoeal or septic ; haematosalpinx, which is often associated 
with tubal gestation, or produced by some interference with the due 
flow of blood during a menstrual period. 

Enlargements of the ovary may be cystic or solid. Ovarian cystoma 
is the most common form of ovarian tumour. It is frequently multi- 
locular, and may have undergone change ; especially from congestion due 
to impaction of the tumour, or twisting of the pedicle ; and inflammatory 
mischief may alter the character of the fluid to blood or pus. Der- 
moid tumours of the ovary frequently occur in young subjects, and are 
associated with the formation of dermoid structures, such as bone, teeth, 
hair, skin ; these, if left untreated, frequently suppurate and discharge 
through the bladder, vagina, or elsewhere. Fibroma of the ovary and 
malignant disease of the ovary, giving rise to solid tumours, are rare 



DIAGNOSIS IN GYNECOLOGY 177 

conditions. Papilloma, a semi-malignant disease of tlie ovary, is apt to 
find its way through the surface and give rise to deposits associated with 
the presence of a considerable amount of free fluid, often blood, in the 
abdominal cavity. 

Parovarian cysts are nearly always unilocular and contain clear fluid ; 
otherwise they have much the physical characters of ovarian cystoma. 

Local effusions of serum, pus, or blood into the cellular tissue of the 
pelvis sometimes spread beyond the pelvic region into the abdomen 
beneath the peritoneum ; and find their way to the abdominal wall, into 
the groin, behind to the region of the kidney, or to the buttocks and 
vulva. Similar localised effusions into the pouch of Douglas frequently 
extend upwards into the abdomen, but are there usually limited b}^ 
matting together of the intestines. 

Among abdominal tumours may be included pelvic adhesions, which, 
by the matting together of the intestines, frequently give rise to the 
impression of a very distinct swelling over which a certain amount of 
resonance can usually be obtained. 

Examination by the Vagina. — In making the vaginal examination 
it is advisable to deal first with the external parts. 

Any signs of irritation on the skin^ such as redness, inflammation, or 
excoriations, will be noted. In some cases, in consequence of irritation, 
an eruption, usually of an eczematous character, appears. The condi- 
tions under Avhich this is found are usually such as to give rise to an 
irritating discharge, as in cancer of the cervix or body of the uterus, in 
sloughing fibroids, and in some other conditions which have already 
been mentioned, such as erosions ; and in cases of gonorrhoea and severe 
vaginitis, not necessarily of a local specific character. Signs of irri- 
tation may also be present in cases of masturbation; or again, when 
the uterus is procident, and the vaginal walls, thrust outside, are irritated 
by friction. In certain cases also of urethral caruncle irritation is set 
up ; and, finally, in diabetes the irritation by the decomposing sugar 
produces considerable irritation, and even an intractable form of eczema. 

The labia majora and minora may be hypertrophied. In patients 
subjected to the above-mentioned sources of irritation more or less 
hypertrophy often occurs. 

The clitoris, too, is a structure which varies considerably in size, and 
is, in some cases, hypertrophied. 

Tlie orifice of the urethra may show signs of irritation, more espe- 
cially where that irritation is associated with pain in passing water. 

In examining the vidua, its size, the colour of the surface, the pres- 
ence of varicose veins or of ulcers on the surface, of abscesses or cysts 
in the deeper structures, should be noted ; and also whether there be a 
discharge bathing its surface, or signs of chronic irritation about the 
parts, as is frequently evidenced by the presence of small warts. Ex- 
pansion of the vulva results from child-bearing, especially where the 
woman has had many children, and in its more marked forms from 
prolapse of the vaginal walls and falling of the womb ; it is especially 



lyg SYSTEM OF GYNAECOLOGY 

prone to occur when not only the parts in the pelvis, but the tissues 
generally are wanting in tone. On the other hand, the vaginal entrance 
may be smaller than usual from congenital causes ; or from spasm, as 
in vaginismus. 

The colour of the mucous membrane will indicate congestion, either 
active or passive, or inflammation. In congestion it takes on a sort of 
peach bloom hue, or varies from that to purple, as in the case of pregnancy, 
and of some tumours in the pelvis, particularly fibroid tumours ; this 
change may occur also in cases of heart and liver disease. In inflam- 
matory conditions the redness is often associated with much swelling 
of the tissues. Varicose veins are specially apt to appear during preg- 
nancy, from the pressure of tumours in the pelvis or abdomen, or from 
some general condition associated with deficient return of blood to the 
heart, such as takes place in disease of the heart or liver. 

Various forms of ulcer may be met with about the vulva. Simple 
ulcers often occur as the result of delivery, as in the case of a tear fail- 
ing to heal ; or as the result of distension of the parts in the course of 
examination, especially where a speculum has been used. Syphilitic 
ulcers are commonly found about the orifice. As the result of acute 
syphilitic diseases in children, severe ulceration, and even sloughing 
and gangrene of the parts, is apt to occur. 

An abscess about the vulva raises suspicions of gonorrhoea. Abscess 
of Bartholini's gland, indeed, is often the result of gonorrhoeal infection 
spreading up the duct of the gland and involving the gland itself: 
abscesses, however, about the vulva are not necessarily gonorrhoeal. 

The form of cyst usually found at the vulva is produced by a 
blocking of the duct of Bartholini's gland and retention of the fluid. 
When the cyst has persisted for some time the walls become consider- 
ably thickened, and the only satisfactory way of dealing with it is to 
dissect it out. 

The discharge about the vulva may be of a simple or specific char- 
acter, and is apt to occur in association with fibroids and polypi, can- 
cerous disease of the uterus (cervix or body), erosion of the cervix, in 
diseases of the lining membrane of cervix, body, and Fallopian tubes, 
as well as in cases of general weakness and gonorrhoea. 

Cancer, beginning primarily at the vulva, though by no means un- 
known, is exceedingly rare. 

The posterior part of the vulva and the perineum should next be 
examined, and a note made whether the fourchette has been torn. 

The hymen in the virgin is various in form. Usually it is a crescentic 
fold of greater or less depth, complete at its circumference and having a 
free, complete edge. When connection takes place it usually happens that 
one or more splits occur in the free margin, but no part of the circumfer- 
ence is lost. As the result of delivery, if at term almost invariably, 
and often even when the patient has not reached the full time of 
pregnancy, parts of the hymen become lost; it is then represented by 
little pieces left at the circumference with vacancies between them, and 



DIAGNOSIS IN GYNAECOLOGY 



79 



of course the whole vulva becomes at the same time more distended than 
it was before. Parts of the hymen may also be lost on account of in- 
hammatory disease and ulceration and sloughing, syphilitic or otherwise. 
The hymen may be thick and fleshy, instead of thin and membranous ; 
and such a hymen is very likely to resist laceration during connection, 
and occasionally even during delivery ; especially if the child be small 
and the patient have not reached the full time of gestation. In another 
form of virginal hymen occasionally met with the vulva is closed by the 
membrane, which has, however, small holes here and there in it — the 
cribriform hymen, as it is called. In other cases the hymen is exceed- 
ingly tough and elastic, and the membrane is larger than usual, leaving 
only a small orifice in front. In such cases also the membrane may es- 
cape laceration, but, being distensible, it becomes considerably stretched 
by efforts at connection. Finally, the hymen may be imperforate ; if so, 
when puberty is reached retention of the menses occurs, and the flow, 
distending the vagina and uterine cavity, causes the membrane to bulge 
outwards. 

In examiniug tlte vagina, the size of it, the character of the mucous 
membrane, the presence of discharge, tendency to prolapse, pessaries 
or foreign bodies contained within it, and cysts or growths in its wall 
are to be ascertained. 

The vagina in the virgin is much shorter than in persons who have 
had connection, though it varies much in individual subjects : it is still 
more enlarged by the process of parturition. The tone of the vagina 
should be noted ; for when the tissues are lax and wanting in tone the 
vagina may be exceedingly large. Perhaps the largest vaginas we meet 
with occur in hysterical women, in whom what is known as '• ballooning " 
of the vagina occurs ; so far as I am aware no very satisfactory expla- 
nation of this condition has yet been given. The vagina may also be 
capacious in persons who have worn pessaries for uterine displacements 
or other conditions. 

The colour of the mucous membrane of the vagina, as of the vulva, 
indicates the existence of gestation, the presence of some tumour, or a 
congested condition produced by more or less general disease or local 
inflammation. On examination, especially with the speculum, one may 
come across spots either redder or paler than the general surface of the 
mucous membrane : the exact significance of these spots, I believe, is 
as yet unknown. 

Ulcers may also be found in the vagina, either of a simple or 
syphilitic character. 

Finally, some discharge may be present, and its quantity, colour, and 
consistence should be observed. It may be watery ; or thick and yel- 
low ; or thick and clear like unboiled white of Qgg\ almost jelly-like 
in consistence : or milky and opaque. 

The walls of the vagina are prone to eversion and prolapse. Pro- 
lapse of the anterior wall with the bladder (cystocele) is the more com- 
mon. If this condition be not well marked it may pass unrecognized, 



i8o SYSTEM OF GYNECOLOGY 

unless the patient be directed to hold her breath and strain down, or 
she be examined in the standing posture. 

Eectocele — a prolapse of the posterior vaginal wall involving the 
rectum — is less common/ though frequently the two occur together. On 
further straining the cervix will often come down and pass the vulva ; and 
in the worst cases even the fundus will hnd its way outside, the vaginal 
walls being completely everted, complete prolapse of the bladder, uterus, 
and frequently of the rectum as well, taking place. The presence of the 
bladder outside may be demonstrated by passing a sound into the bladder 
and observing the position of the point in the prolapsed mass. Eectocele 
may be recognised by passing the finger into the bowel. 

The presence of pessaries or foreign bodies in the vagina will not 
escape notice. Pessaries are sometimes put into the vagina without 
the knowledge of the patient ; or may sometimes be forgotten and left 
there for a considerable time. Their presence is apt sooner or later 
to set up vaginitis, unless the patient takes means to ensure cleanliness 
by the use of vaginal douches. 

Cysts, by no means common, are occasionally found even at the upper 
part of the passage. A case sent to me as one of small ovarian tumour 
proved to be a cyst at the roof of the vagina. The wall of the vagina is 
frequently infiltrated by malignant disease extending from the cervix. 

Tlie cervix may be outside the vagina, or high up, even out of reach, 
especially when the bladder is full ; it may be just within the vulva ; it 
may be far forwards; it may be backwards on the perineum, or back- 
wards and high up ; or it may be to one side or other of the middle line. 
Its shape is to be noted. The length of the vaginal part of the cervix — 
the part, that is, which projects into the vagina — must be observed ; its 
consistence also ; its mobility, whether it appears to be free or attached 
and limited in its movements ; the condition and colour of the mucous 
membrane will be seen by using a speculum (generally, for purposes of 
diagnosis, a Fergusson's speculum) ; as also any erosion on one or other 
lips of the cervix, or ulceration ; and, finally, the secretion passing from 
the cervix. 

In speaking of the conditions which cause the position of the cervix 
to vary I must anticipate a little, for the position of the cervix has often 
to be considered in relation to the position of the fundus. The cervix is 
lower than it should be in cases of prolapsed and of procident uterus, and 
in supravaginal and infravaginal elongation; but when the uterus is 
merely prolapsed or procident the fundus falls with it, and their relative 
position is preserved. In cases of infravaginal elongation, in which the 
cervix is usually lengthened out into a cone surmounted by a small orifice, 
the fundus maintains its proper position ; but the cervix itself is elongated 
and the canal lengthened. This is a congenital affection usually associated 
with dysmenorrhoea and, if the patient be married, with sterility also. 
In cases of supravaginal elongation the intravaginal cervix is not elon- 
gated; but the cervix falls while the fundus relatively maintains its 
normal position, though it is often associated with some descent of the 



DIAGXOSIS IN GYNECOLOGY i8i 

uterus as a whole- : extension takes place between the attackment of the 
uterus to the parts around and the roof of the vagina. In this case also 
the canal is lengthened In anteflexion the cervix usually maintains its 
position so long as the anteflexion is anteflexion pure and simple ; but 
where version takes place the cervix is found higher up and farther back 
than usual. In retroflexion pure and simple the cervix maintains its 
position though the body fall ; but when retroversion takes place the 
cervix approaches the symphysis while the body tilts backwards. 
Anteflexion is not infrequently found in association with retroversion, 
in which case the body falls in the pelvis, and at the same time the 
cervix approaches the symphysis and its orifice becomes directed 
forwards, often looking towards the top of the symphysis instead of 
downwards and backwards. Irregularity of the cervix may be the 
result of laceration occurring during delivery or in the course of an 
operation. Lacerations occurring during parturition are more frequently 
found on the left than on the right side, and if both sides are involved 
the left is usually more so than the right. Where, too, bilateral lacer- 
ation has occurred, the lips of the cervix may become averted so that 
they actually fall into the same plane. All cases of flexion and 
version are apt to be accompanied by some descent of the uterus as 
a whole. Carcinoma produces more or less irregular nodulation either 
in the substance of the cervix or on its surface, Avhich imparts to the 
examining finger a gristly feel. A cauliflower excrescence springing 
from the cervix may be at once put down to malignant disease. In 
consistence the cervix may be rendered much harder than usual by 
chronic inflammation set up in consequence of lacerations and tears, such 
as occur after repeated deliveries, especially where instruments have 
been used. Primary S3'philitic sores are rarely found on the cervix, but 
when present preserve their usual hard character. The cervix is rendered 
hard also by malignant disease which, after a time, breaks down towards 
the centre, still leaving a hardened infiltrated margin. In consistence it 
is diminished in pregnancy, in subinvolution, and in many cases of 
inflammation of the lining membrane, especially when associated with 
haemorrhage and copious discharge. The mobility of the cervix may be 
diminished either from the presence of some extraneous tmnour pressing 
the uterus downwards or to one side ; or as the result of some inflamma- 
tor}^ condition with effusion, adhesion, or cicatricial contraction resulting 
therefrom ; or, finally, as the result of cancerous growth in its substance 
which has spread and involved the cellular tissue outside. The mobility 
is abnormally increased when the parts are lax and the ligaments have 
become stretched, as occurs in cases of prolapse, procidentia, etc. 

The colour of the mucous membrane will indicate congestion or 
inflammation. In cases of metritis it becomes of a florid red colour ; its 
colour is dull or bluish when the blood-supply is partially arrested, either 
from incomplete strangulation, as in prolapse ; or from the pressure of 
tumours in the pelvis or abdomen; or as the result of inflammatory 
effusions, or of obstruction to the circulation in disease of the heart and 



i82 SYSTEM OF GYNECOLOGY 

liver. In prolapse of the vaginal walls tlie mucous membrane after a 
time becomes thickened and the surface dry. 

Erosions vary much in appearance. Sometimes they are florid; 
sometimes they are oedematous and readily bleed when touched. When 
healing they take on a bluish line at the margin : the part which has 
healed over, which has become cicatrised, that is, with a stratified layer 
of epithelium, is of a whity-bluish colour, different from the rest of the 
cervix. Proliferation of the gland structures often takes place ; the 
follicles become distended with mucus, and, the ducts being plugged, 
the follicles stand out as glistening points dotted over the surface of 
the erosion. 

Simple ulceration is uncommon, except as the result of laceration 
or of caustic applications. Syphilitic ulceration — a hard sore of the 
cervix — is occasionally met with and has the same characters as hard 
chancres elsewhere. 

The secretion from the cervix is naturally a thick glairy mucus, but 
in cases of severe inflammatory mischief it often becomes purulent. 

The presence of mucous polypi in the cervix itself, growing from the 
lax mucous membrane, is usually associated with a very considerable 
amount of secretion from the canal and often with haemorrhage. 

Tlie body of the uterus may present changes in size, shape, consistence, 
or mobility ; and it may be tender to the touch. 

The displacements of the body which may be met with are prolapse 
— that is to say, a falling downwards, which, when existing to a marked 
extent, is known as procidentia ; anteflexion ; retroflexion ; anteversion 
and retroversion; and a combination of anteflexion and retroversion. 
Lateral displacements may sometimes be observed, especially where a 
growth or swelling in the broad ligament displaces the uterus to the 
opposite side, or adhesions draw it to the same side. But lateral 
displacement may be congenital from a shortening of the ligaments on 
the side to which it is inclined. Extraneous tumours may displace the 
uterus downwards — as does ovarian disease, which frequently at the 
same time produces retroversion ; upwards — as does especially a full 
bladder ; forwards — as by any swelling in the pouch of Douglas, such as 
hsematocele, or a mass of faeces in the rectum ; backwards — as again by 
a full bladder or ovarian cyst ; and laterally — as by any swelling in the 
broad ligament itself, such as an extra-uterine gestation, a parovarian 
swelling, or sometimes a small ovarian tumour. 

The uterus may be found of less than normal dimensions ; either as 
a congenital defect, in which case the ovaries may also be absent or 
imperfectly developed; after delivery as the result of what is known as 
superinvolution ; or at the menopause, as the result of natural atrophy. 

The uterus frequently increases in size. Eor purposes of diagnosis 
it is well to divide these enlargements into those which are regular in 
character, and those which are of an irregular form. Uniform or regular 
enlargement occurs in gestation ; and, of course, such enlargement is also 
met with after delivery, in the lying-in period, before the uterus has 



DIAGNOSIS IN GYNECOLOGY 183 

returned to its normal dimensions, and in cases of subinvolution. In 
cases of inflammation (metritis and endometritis) the uterus is in- 
creased in size ; the sound usually passes half an inch to an inch more 
than the natural distance. In cases of mole pregnancy a regular en- 
largement of the uterus occurs; though occasionally an irregular bulg- 
ing may be found — especially in blood mole — over the site of the 
effused blood. Again, more or less regular enlargement of the uterus 
takes place in cases of pyometra and hsematometra ; cases, that is to 
say, of pus and blood inside the uterine cavity. Pyometra is usually 
met with in old women, but is not a common condition ; hsematometra, 
as a rule, belongs to cases of imperforate hymen. 

Among irregular enlargements of the uterus, myomas or fibroid 
growths are the most common. Cancer of the uterus also produces 
more or less irregular enlargement of the body ; though it may appear 
uniform, as it may also in enlargement due to fibroid. Cancer of the 
body, in comparison with carcinoma of the cervix, is a rare disease, 
occurring late in life. Sarcoma of the body, another rare condition, 
also produces more or less irregular enlargement. 

As regards consistence, we may take it as a general rule that soft 
enlargements of the body of the uterus are usually the result of ges- 
tation, when, be it noted, there is a hard body inside the fluid one. 
In hydatidiform mole enlargement takes place rapidly and is of a 
soft character. In subinvolution the consistence is diminished ; and 
the same description usually applies to metritis unless it has become 
chronic ; and also to pyometra and hsematometra, unless the distension 
be very great, in which case the enlarged organ is hard. In rapidly 
growing fibroids and fibro-cystic swellings the enlargement is usually 
soft and semi-fluctuating, and a uterine bruit may often be heard. 

The enlargements, in which the consistence is increased, are usually 
the result of fibroid masses, unless rapid growth be taking place or 
oedema be also present, as for instance when the enlarged uterus be- 
comes impacted in the pelvis. Cancerous enlargements are usually hard ; 
so also are sarcomatous tumours. Blood and fleshy moles (in contradis- 
tinction to hydatidiform moles) cause abnormal hardness of the uterus. 

In considering the mobility of the uterus, it has to be remembered 
that it is usually increased, as the result of laxity of the tissues, by 
frequent child-bearing or by operations in which the uterus has been 
dragged upon. It is decreased as the result of extraneous tumours pre- 
venting free movement, whether these tumours be above, below, to one 
side, or at the back of the uterus. In cases of inflammatory mischief 
the uterus may be either pushed to one side by the effused products, or 
drawn by adhesions to surrounding structures ; or, if the effusion have 
occurred in the cellular tissue ; it may be drawn and fixed by the con- 
traction which subsequently occurred. In any case the movements of 
the uterus are restricted. The mobility is decreased also by new 
growths spreading and involving the tissues beyond the uterus, as in 
cancer and sarcoma ; or when from any cause the uterus falls into the 



1 84 SYSTEM OF GYNECOLOGY 

pelvis and becomes impacted. In severe cases of retroflexion and of 
retroversion the fundus may be grasped and lield down in the floor of 
the pouch of Douglas by the sacro-uterine ligaments. 

The uterus becomes tender to the touch from congestion, from in- 
flammation of the tissue of the uterus itself, or from such inflammatory 
mischief, in the immediate neighbourhood, as occurs in ovaritis, pro- 
lapsed ovaries with congestion, pelvic peritonitis, and, lastly, as the 
result of adhesions to surrounding structures. 

Tumours in the Pelvis. — In investigating pelvic tumours the x^oints 
to be noted are their position ; their size ; their shape ; their consist- 
ence ; their mobility ; the presence of tenderness on manipulation ; and 
their apparent attachment, which is estimated by endeavouring to move 
the tumour, and ascertaining upon what parts it appears to drag, and 
upon what parts the movement of the tumour has no effect. 

The tumours in the pelvis may be divided, according to the part 
from which they originate, into eight heads, as follows. (In this cate- 
gory tumours of the vagina and vulva are not included because those 
affecting the lower part of the canal have been already mentioned.) 

i. Tumours of the Uterus itself are — Inversion, either partial or 
complete. Fibroid polypi, which may be either in the vagina, lying in 
the cervix of the uterus and distending it, or still remaining in the 
cavity of the uterus : myoma of the cervix very frequently grows down 
into the vagina, occasionally into the broad ligament : myoma of the 
body of the uterus begins in various parts and grows in various direc- 
tions as submucous, interstitial or subperitoneal. Fibroids are frequently 
multiple, and interstitial growths are frequently found in association 
with a polypus or a subperitoneal fibroid; as they grow, they may ex- 
tend into the broad ligament, especially when they begin low down or 
on one side of the uterus, and subperitoneal fibroids are apt to fall into 
the pouch of Douglas and become impacted there. Cancer of the cervix, 
subsequently extending to the body as well as to the vagina : primary 
cancer of the body. Sarcoma of the body of the uterus. The body of 
the uterus itself, taking up a faulty position, such as has been already 
mentioned in retroflexion or version, may form a tumour. Retroversion 
of the gravid uterus impacted in the pelvis must also be mentioned. 

ii. Tumours connected with the Fallopian Tubes. — One or both tubes 
may be distended with serum, pus, or blood, giving rise to hydrosalpinx, 
pyosalpinx, and hsematosalpinx respectively ; the tubes themselves being 
usually thickened and adherent. Tubal gestations frequently rupture 
either into the peritoneal cavity, giving rise to hgematocele, or into the 
broad ligament giving rise to hsematoma. Occasionally part or the 
whole of the gestation sac may be extruded from the fimbriated extrem- 
ity (tubal abortion), or, less often, find its way into the uterine cavity. 

iii. Tumours of the Ovaries. — Prolapsed congested ovary, forming a 
swelling not usually of large size, is by no means an uncommon condition ; 
and is frequently found associated with retroversion of the uterus and 
general laxity of the tissues. Cystoma of the ovary, that is to say, the 



DIAGNOSIS IN GYN.HCOLOGY 185 

ordinary cystic ovary ; dermoid tumours of the ovary, and parovarian 
cyst, which is really a tumour of the broad ligament, arise in the ova- 
rian region. 

iv. Tumours of the Cellular Tissue are hsematoma, serous effusion, 
(parametritis), and abscess. 

V. Tumours of the Pelvic Peritoneum are hsematocele ; serous peri- 
metritis, that is to say, a localised peritonitis with effusion ; and abscess. 

Adhesion and the matting together of the intestines, tubes, and 
ovaries in the pouch of Douglas frequently gives the impression of a 
distinct tumour in that situation. A loop of intestine containing faeces 
may easily be mistaken for some other tumour in the pouch of Douglas. 

vi. Tumours connected with the Pectum are faecal accumulation ; 
malignant and other growths. 

vii. Tumours connected with the Bladder. — The most common is 
scarcely worthy to be called a tumour, though it frequently simulates 
one, namely, distension of the bladder from the accumulation and reten- 
tion of urine. Stone in the bladder is a very uncommon condition in 
women, but may occasionally be met with. 

viii. Petroperitoneal Growths are such as lipoma, sarcoma, osteoma 
of the bones of the pelvis ; a contracted pelvis. 

II. Examination by means of the Sound. — For purposes of diagnosis 
the sound serves as a measure of the length of the uterus, of the size of 
the canal, and of its direction ; moreover, by careful use of it other facts 
may be inferred, such, for instance, as disease of the mucous membrane 
from the passage of blood or discharge after its use. To some extent, 
also, the condition of the canal may be inferred by noting whether its 
introduction or removal is associated with pain as it passes the inner 
orifice. 

When the sound touches the fundus it usually produces pain which 
is generally referred to the region of the umbilicus. 

In speaking of the conditions which produce increase in length, it 
must be remembered that after child-birth the uterus rarely returns to 
the size of the unimpregnated organ ; but the difference is usually not 
more than a quarter of an inch. Elongation of the canal may be due 
to subinvolution ; to chronic metritis ; to polypi, submucous and inter- 
stitial fibroids ; to sarcoma and carcinomatous disease of the body ; and 
to supravaginal and infravaginal elongation of the cervix. Shortening 
of the canal may be due to partial inversion (in complete inversion it 
is obliterated) ; to superin volution ; to the natural atrophy which occurs 
after the menopause, and to faulty development. 

The canal may be congenitally narrow, especially at the inner orifice ; 
or contracted and even obliterated by caustic applications ; or as the 
result of operation, for example, supravaginal amputation. The canal 
may be dilated in various conditions during pregnancy and after deliv- 
ery ; also by the passage of polypi and from loss of blood. Its direction 
may be altered by versions and flexions, or by the presence of fibroid 
or other mass encroaching upon its lumen. 



i86 SYSTEM OF GYNALCOLOGY 



IV. Examination by the Bladder and Rectum. — In some cases where 
a tumour seems to be in the pouch of Douglas, but cannot be well de- 
fined, an examination by the rectum may set aside the possibility of its 
rectal origin ; and in many cases examination by the rectum with the 
finger of one hand may be combined with that by the vagina with the 
finger of the other. Examination by the rectum is often of considerable 
use in determining the height of the fundus ; the size of the fundus ; 
the size of the body, and the presence or absence of the ovaries and 
disease of the tubes. In some cases, to determine the size of the uterus 
or the presence or absence of the uterus from its normal position, it may 
be advisable to examine through the urethra either with the sound or 
with the finger ; for instance, in some doubtful cases of inversion. If 
the finger be employed, it is often better to incise the vesico-vaginal 
septum, which readily heals, than to dilate the urethra with the risk of 
permanent incontinence. Examination of the bladder may be combined 
with a digital examination by the rectum. 

In all cases I would recommend a bimanual method in making inter- 
nal examinations ; it is accomplished with far greater ease and ensures 
much greater accuracy. 

V. Additional Means of Examination In some cases, however, it 

will be found that the means already suggested, even if adopted, are 
not sufficient to clear up the nature of the case. Especially is this so 
when the patient is difficult to examine, as in cases of vaginismus ; when 
the parts are contracted ; when the patient holds her breath and strains, 
and particularly when it is necessary to ascertain the exact connections 
of a tumour in the pelvis, and to determine whether it be freely mov- 
able or not. In such cases the advantage of an anaesthetic are very 
great. In other cases, again, some difficulty arises in passing a sound, 
which may get fitted into little pouches in the canal. If the passage of 
the sound be necessary to diagnosis, it is well to fix the cervix with a 
volsella. This does not necessarily involve the use of an anaesthetic in 
married women ; but it is frequently expedient that the examination 
may be complete. In the examination of young unmarried women an 
anaesthetic is often desirable on other grounds. 

There are other cases, again, when it is necessary to dilate the cervix 
and explore the uterus. Dilatation may be effected under an anaesthetic 
with Hegar's dilators ; and it is often called for, not only in deciding the 
cause of haemorrhage from the uterus, but also as a preparatory step in 
operations for its relief. When the cervix is unusually rigid laminaria 
tents may also be used with advantage. 

Finally, it may be necessary, before arriving at a diagnosis, to remove 
portions of tissue for microscopic examination ; as in the case of erosions of 
the cervix of doubtful malignancy, and in cases of haemorrhage from the 
uterus with irregularities of the surface, which may be of a malignant 
nature ; or, again, to determine whether retained products are the result 
of gestation or of some inflammatory condition of the mucous membrane. 

It is not always possible to arrive at a correct diagnosis on first 



INFLAMMATION OF THE UTERUS 187 

seeing the patient ; time is often an important factor in forming a correct 
opinion. But while the precise nature of the case remains undetermined 
the patient may often with manifest advantage be placed under provi- 
sional treatment to give relief to her instant sufferings, and to assist the 
physician in arriving at a complete diagnosis of the case. Take, for 
instance, the case of a swelling in the pelvis, the nature of which is at 
first undeterminable. The symptoms and physical signs point to inflam- 
matory mischief; and for a time it may not be possible to distinguish, and 
to exclude some cystic or other swelling at the bottom of it, such as a rupt- 
ured ectopic gestation. The patient is put to bed and kept quiet ; hot 
douches are ordered to allay inflammation ; and the bowels are regulated 
with a view to avoid irritation of the inflamed jDarts in the pelvis. If, 
after a time, the temperature, w^hich perhaps was considerably raised, has 
under this treatment fallen to normal ; if the tenderness and pain have 
gradually subsided or disappeared ; if the swelling has diminished in size, 
and the parts which were previously fixed have become mobile, it may 
be reasonably concluded that the swelling probably consisted entirely of 
inflammatory effusion. But such cases do not always end thus. For 
example, after the temperature has been normal for a week, and the 
patient has then risen from bed, the inflammatory mischief may reassert 
itself. We are thus led to think that something more than the mere 
inflammatory mischief remains behind ; and after a time some definite 
swelling may be recognised. In cases such as these a correct diagnosis 
can only be reached by care and vigilance. It is important also to have 
the opportunity of noting any changes in the symptoms and physical 
signs while the patient is under treatment, and to be prepared to modify 
the diagnosis according to the results. 



Egbert Boxall. 



REFERENCES 



1. CoHNSTETN, J. "Die .a:yntikoloo:ische Dia^jnostik," Volkrncum's Sammlung, No. 
89. Leipzig, 1875. — 2. Keating, John M. and Henry C. Coe. Clinical Gi/n serology, 
Medical and Surgical, by American Teachey^-'^, 2 vols. Edin. and Lond. 1895. — 3. Mann, 
Matthew D. A Syatem of Gynecology by American Authors, 2 vols. Edin. 1887, 
1888. — 4. Pean, J. Diagnostic et traitement des tumeurs de Vabdomen et du bassin, 2 
vols. Paris, 1880, 1885. — 5. Veit, Johann. Gynakologische Diagnostik. Stuttgart, 
1891.— 6. Wells, T. Spencer. Diagnosis and Surgical Treatment of Abdominal 
Tumours. Loud. 1885. 

E,. B. 



INFLAMMATION OF THE UTERUS 

Few subjects in gynsecology are so difficult to handle as inflammation 
of the uterus. Seldom fatal, and therefore not lending itself to the pre- 
cise methods of the pathologist, its pathological anatomy is being but 
slowly w^orked out. Clinically it includes a long series of cases showing 



SYSTEM OF GYNECOLOGY 



the most varied changes. Beginning with those in which the only 
symptom is pain, and the only physical sign undue sensitiveness on 
examination, — cases which led that careful clinician Gooch to describe 
what he called the " irritable uterus," — it further signifies groups of 
cases which show all the marks of local inflammation, but usually present 
no distinct line of demarcation between the acute and the chronic. Be- 
sides being rarely fatal, except in cases of puerperal sepsis, which belong 
rather to the domain of obstetrics than of gynaecology, another peculi- 
arity of inflammation of the uterus is the rarity of suppuration which is 
so common a result of inflammation in other organs. We are not sur- 
XDrised, therefore, to find a great divergence of opinion among leading 
gynaecologists in Britain and elsewhere on the nature and relative im- 
portance of the various forms of uterine inflammation. 

A retrospect of the opinions held during the last half century on the 
significance of the various inflammatory lesions in the pelvis brings out 
two curious facts. The first is the influence of methods of examination 
in accentuating a lesion. The speculum concentrated attention on the 
cervix, the sound on the position of the uterus ; the bimanual examina- 
tion on the cellular tissue and peritoneum ; the exploratory incision on 
the uterine appendages, and the microscope on micro-organisms. On the 
introduction of each of these methods of examination the corresponding 
lesion has been emphasised out of all proportion to the rest. An expert 
in any one method of examination is disposed to say — This is the lesion, 
and there is no other. At present abdominal section and the microscope 
hold the field ; and a historical survey warns us that at the present time 
we are exposed to the danger of emphasising the significance of inflam- 
matory lesions of the uterine appendages, and even of the part played 
by micro-organisms, at the expense of other lesions and other factors of 
no less importance. 

Another striking feature in such a retrospect is the progress in the 
mode of regarding disease. Half a century ago the standpoint was a 
symptomatic one. Tyler Smith's book on Leucorrhma, in which the most 
varied conditions are grouped together because they have this symptom 
in common, is an illustration of the symptomatic standpoint. At the 
present day the standpoint is pathological; the "entity leucorrhoea" 
has been replaced by " endometritis " and " cervical catarrh," under 
which names the lesion is localised and described. But the changed 
standpoint does not simply mean seeing another side of the same thing. 
We are not merely walking round a hill, we are ascending it ; the 
pathological standpoint is a step higher than the symptomatic : a step 
higher still will bring us to an etiological standpoint, inasmuch as 
etiology deals with causation, and is the basis of preventive medicine. 
W^here it has been demonstrated, as in the case of gonorrhoea, that the 
inflammatory conditions of the uterus are due to a micro-organism, this 
view of inflammation from the etiological standpoint has simplified our 
conception of it. Instead of being broken up artificially into different 
affections according to the tissues involved for the time being, it has 



INFLAMMATION OF THE UTERUS 189 

become an organic unity, gathered round the life-history of a micro- 
organism. Clinical experience tells us that this is the true mode of 
regarding it. 

And yet, if it should be shown that all the changes which we associate 
with metritis have a microbe at the bottom of them as the essential factor 
in their production, this would not produce a great revolution in our con- 
ception of metritis, although it would materially influence our treatment 
in so far as it might emphasise preventive treatment by antiseptics. 
After all the micro-organisms have been discovered and described, atten- 
tion will again revert to the local and general conditions which determine 
their growth. If the microbe or spore be the seed the uterus is the 
soil, and those subtle influences which we speak of as constitution and 
diathesis are the climate. The seed is an essential factor in plant life, 
but equally important factors for development and growth are soil and 
climatic conditions. The discovery of the seeds has for the time thrown 
the study of constitutional states and diatheses into the background. 
But because we know little about them we need not minimise their 
influence. No science is so vague as meteorology, and yet nothing 
bulks so largely in the farmer's mind as the weather. Of the importance 
of soil no better illustration could be found than in the case of the puer- 
peral uterus. If Winter's observations are correct, the staphylococcus 
pyogenes albus, aureus, and citreus, as well as various forms of strepto- 
cocci, are present beforehand in the uterus, but lie harmless until the 
puerperal state supplies the conditions favourable for their development. 

To Henry Bennet is due the credit of drawing attention to the 
importance of inflammation of the uterine mucous membrane (2). 
Although he described it as in many cases going on to ulceration, so 
that his opponents fastened on the alleged " ulceration," and criticised 
it as the essence of Bennet's teaching, it is only fair to him to say that 
he regarded ulceration as but one of many phases of inflammation. 
Perhaps he laid himself open to criticism by stating that inflammation 
was to be treated by surgical means. 

Bennet's views were opposed by Lee and West (40) and Tyler Smith. 
In reaping their criticisms it is interesting to come upon statements, then 
based only on clinical observation, which have since been established by 
microscopic investigation. Thus Lee, speaking of the appearances which 
Bennet described as ulceration, says : " These apparent granulations are 
usually considered and treated as ulcers of the os and cervix uteri, but 
they do not j^resent the appearances which ulcers present on the surface 
of the body, or in the mucous membranes lining the viscera, and they 
are not identical with the granulations which fill up healthy ulcers. They 
present the appearances often observed on the tonsils which are said to 
be ulcers, and are not " (21). Thus Lee, writing in 1850, forecasts the 
work of Ruge and Veit in 1878. The comparison of the " ulcerated " 
cervix to a hypertrophied tonsil is a happy one. So also Tyler Smith 
forestalled the view of Emmet and Eoser, that the appearance is pro- 
duced by an ectropion of inflamed cervical mucous membrane, when he 



I90 SYSTEM OF GYNAECOLOGY 

says : " The granulations which are sometimes found surrounding the os 
uteri — which may secrete mucus or pus abundantly, and which may bleed 
on being roughly handled — are, I have no doubt, the result of inflamma- 
tion ; but they resemble the granular state of the conjunctiva rather than 
the granulations of a true ulcer, the granular os uteri offering no edges or 
signs of solution of continuity, by which we might satisfactorily declare 
it to be an ulcer (37)." 

Unfortunately, and in spite of such criticism, the term "ulceration," 
introduced by Bennet, took hold of the professional mind. It led to a 
routine treatment of inflammatory conditions of the cervix by caustics, 
as slowly healing ulcers in other situations are treated. An erroneous 
pathology opened the door for a pernicious treatment, from which British 
gynsecology suffered until it found a true pathological basis. 

Etiology of Uterine Inflammation. — While for descriptive purposes 
Ave divide inflammations of the uterus into inflammation of the cervix or 
cervical catarrh, of the mucous lining of the body or endometritis, and of 
the substance of the uterus or metritis, it must be borne in mind that no 
one of these occurs by itself. Before looking at these conditions sepa- 
rately it will be convenient to consider the etiology of all three together, 
inasmuch as they are produced by the same causes. Clinically the inflam- 
mation is not limited to any one tissue ; and all that is meant when a 
case is spoken of as endometritis, is that the changes in the mucous mem- 
brane in the body of the uterus are for the time being more prominent. 

In studying the etiology of inflammation of the mucous membrane of 
the uterus, we must bear in mind that the uterine mucosa is not func- 
tionally analogous to other mucous membranes, as for example those of 
the stomach, the respiratory tract, or bladder. These belong to organs 
whose function is constant and necessary to life. They are in daily use, 
while the function of the uterus, namely, reproduction, is only called into 
exercise occasionally. Even the periodic changes connected with men- 
struation can hardly be considered as a function necessary to life, for 
there is no evidence to support the old idea of its being a monthly cleans- 
ing or katharsis, which would make the uterus practically an excretory 
organ. Menstruation is connected with the function of reproduction, and 
its occurrence is not necessary to life. If then the uterine mucosa be not 
analogous to other mucous membranes, we must be cautious in transfer- 
ring to the etiology of its diseases notions gained from the study of patho- 
logical processes in these others. Thus we are prepared for the fact that 
many of the processes which we have to describe under endometritis 
are more allied to new formation than to inflammation, or at any rate, 
to the inflammation we are accustomed to study in mucous membranes 
elsewhere. Were we to subject the heterogeneous mass of pathological 
conditions grouped under endometritis to exact criticism, much would 
disappear and the residuum would be small. Thus endometritis fungosa 
is more of the nature of a new growth than of an inflammatory process ; 
the glandular form of endometritis is more akin to an adenoma than to a 



INFLAMMATION OF THE UTERUS 191 

catarrh of a mucous membrane ; and many cases of endometritis after 
abortion should, according to Ktistner, be considered as deciduomas. 

Pozzi, however, in his admirable chapter on Metritis in his treatise 
on Gynaecology, justifies the grouping of these varied conditions under 
Metritis, because they have these features in common — that their com- 
mencement is an infective process, and their evolution defensive and 
limiting in its action. This, however, does not exhaust the features of 
an inflammation as contrasted with a neoplasm. The final product of 
an inflammatory process is a degenerated tissue rather than the tissue 
characteristic of the organ in which it has occurred. Of the former we 
have illustrations in those forms of endometritis which end in the de- 
struction of the mucosa ; of the latter in those wdiich end in hypertrophy. 

On the other hand, the uterine mucosa, and especially that of the 
cervix, is analogous to other mucous membranes in its tendency to be 
affected in certain diatheses or constitutional states. Thus in tubercu- 
losis and syphilis, in rheumatism and gout, in anaemia and chlorosis, there 
is a tendency to cervical catarrh as there is to bronchial or gastric catarrh. 

We are not yet in a position to classify satisfactorily the causes of 
uterine inflammation. All we can do, in the present state of our know- 
ledge, is to arrange them in two groups, — those which are constitu- 
tional, and those which are local. It is evident that this classification 
is not satisfactory, because in many cases the factor is a micro-organism 
which, as it gains access through the mucous membrane, is a local cause, 
but in so far as the whole system becomes affected by it, is a general 
cause. 

The constitutional causes of uterine inflammation are even more 
deserving of study than the local causes. Being less obvious, they do 
not force themselves upon our attention: more subtle in their action, 
they are more difficult to estimate ; and the more their constitutional 
quality, the more difficult they may be to treat. In scrofula and tuber- 
culosis there is a tendency to uterine catarrh, affecting specially the 
cervix ; as there is a tendency in the same diathesis to bronchial or gas- 
tric catarrh. So also in patients suffering from rheumatism and gout, we 
find a similar tendency, and likewise in girls suffering from anaemia and 
chlorosis. Apart, indeed, from any special diathesis, a generally en- 
feebled state of the constitution will bring out tendencies to cervical 
catarrh, as it may to tonsillitis. Hence the gynaecologist must direct 
his attention to those modes of life which tend to undermine the health. 
Once we fully appreciate the connection between the general health and 
local conditions, we shall make out a strong case against the current mode 
of bringing up young girls, especially during the years of school educa- 
tion. The present system undoubtedly favours the development of 
menstrual disturbances which frequently end in uterine inflammation. 

Passing from constitutional states to specific diseases, we find that 
the uterine mucosa, like other mucous membranes, is affected in the 
course of the exanthemata. Thus in measles, scarlatina, and small-pox, 
as well as in typhoid fever and cholera, endometritis is liable to occur. 



192 SYSTEM OF GYNECOLOGY 

In the recent influenza epidemic menorrhagia was a not infrequent 
symptom. Gottschalk found haemorrhages in the uterine mucosa in 
influenza, but no microbes. Organic diseases which favour passive con- 
gestion also lead to inflammatory changes in the uterus. Thus in dis- 
eases of the heart and kidney, and especially of the liver, uterine 
inflammation may be present, and can only be dealt with by recognising 
and treating the primary affection. 

Inflammation of adjacent organs excites inflammatory changes in the 
uterus, apart from simple extension of inflammation. This occurs in 
inflammation of the uterine appendages, and especially of the ovaries. 
Czempin, who has studied this point in patients in Dr. Martin's clinique 
in Berlin, mentions four kinds of such causes : inflammation of the ova- 
ries with or without that of the tubes; old parametritis which has 
become acute ; irritation of the peritoneum, as in cicatrices after Tait's 
operation and ovariotomy ; and other slowly developing conditions of 
the appendages, such as pyosalpinx and sarcoma of the ovary. Should 
an etiological relationship be established between disease of the appen- 
dages and uterine inflammation, it will give additional reason for the 
removal of the former when diseased. 

Irritation of the rectum also keeps up uterine inflammation, and the 
latter has been known to disappear on removal of a rectal polypus. 

Passing now to the local causes, we note the importance of exposure 
to cold or great fatigue at the menstrual period. If a woman take a 
chill during menstruation its effects will probably appear in the pelvic 
organs. And apart from undue exposure, the congestion of the men- 
strual periods plays a very important part in the exacerbations of uterine 
inflammation. 

The ovaries play a special part in the development of endometritis. 
Brennecke, who has drawn attention especially to this point, makes one 
group of cases of endometritis fungosa arise under their influence. These 
cases are characterised at the outset by amenorrhoea for one or two periods. 
This he explains by the ovarian stimulus, which, while exciting the hy- 
pertrophy of the mucosa which precedes normal menstruation, is insuffi- 
cient to cause hsemorrhage. Thus arises a hyperplasia of the mucous 
membrane from which hsemorrhages afterwards occur. I have not seen 
any cases of endometritis beginning with pathological amenorrhoea, such 
as Brennecke describes, but have always been able to account for the 
amenorrhoea by an early abortion. On the other hand, the irregular 
bleedings at puberty point to a tendency to endometritic changes in 
connection with the initiation of the functions of the ovaries. 

Pelvic congestion, due to excessive sexual intercourse or to mastur- 
bation, is also given as a cause of uterine inflammation. In prostitutes 
cervical catarrh is common, but this is probably the result of gonorrhoeal 
infection. 

Septic infection occurs usually in connection with the puerperal state, 
whether after abortion or labour. In this state we have a combination 
of circumstances favourable to septic infection ; namely, raw surfaces, 



INFLAMMATION OF THE UTERUS 193 

dead matter liable to decompose, and low vitality of the tissues. It is, 
therefore, in the puerperal state that we find the best examples of acute 
metritis, and in connection with it the pathology of the malady has been 
chiefly studied. Hence acute metritis as described in the text-books 
concerns the obstetrician rather than the gynaecologist. The pathology 
of the chronic forms of uterine inflammation which come under the 
attention of the gynaecologist is being worked out but slowly ; they are, 
however, likewise septic in origin. This is a fact which cannot be too 
much insisted on, as it gives the reasons of the treatment which is here 
preventive, and consists in carrying out thorough cleanliness with anti- 
sepsis in all gynaecological work. The activity of germs depends in part 
upon the media in which they are cultivated. Some that have lost their 
virulence regain it in a favourable soil. And the post-j^artum uterus is 
practically an incubator, at a suitable temperature for their develop- 
ment, containing the necessary pabulum in the form of retained decidua 
or blood-clot ; we can therefore understand how the microbes may mul- 
tiply and become virulent there. Abortion, even more frequently than 
full-time labour, is the starting-point of uterine inflammation, owing in 
part to the greater tendency to retention of portions of the ovum, and 
in part to the fact that patients do not take the same care of themselves 
after abortion. Lacerations of the cervix [see " Morbid Conditions of 
the Female Genital Organs resulting from Parturition " in this System], 
which occur in abortion as in labour, form channels for septic absorption 
and consequent cervical catarrh ; and in a large proportion of cases we 
may trace the inflammation back to such causes. The interior of the 
uterus after delivery also is practically a large raw surface; hence en- 
dometritis in multiparae can often be traced back to the puerperium. 
The term subinvolution, introduced by Sir James Simpson, covers all 
the changes in the cervix, the endometrium, and the body of the uterus 
thus produced during this period. 

Besides acting as foci for the production of septic material, portions 
of retained decidua occasionally cause endometritis by maintaining their 
vitality instead of breaking down in the lochia. In such cases islets of 
decidual cells have been described in the inflamed endometrium. We 
have thus a form of endometritis after abortion which is a new formation 
rather than an inflammation, and which can only be treated by the 
curette. 

The introduction of septic matter by the gynaecologist in his use of 
septic sounds or tents, or the neglect of antiseptics in operations, need 
only be mentioned as sources of uterine inflammation which should not 
exist, and which are becoming rarer as the importance of antiseptics is 
generally recognised. 

If in fertile women puerperal sepsis is the most important cause of 
uterine iuflammation, in sterile women the ravages of the gonococcus are 
deserving of careful study. TVhile those who have written on gonorrhoea 
certainly convey the impression of exaggerating its frequency, it is 
nevertheless a malady which, in its subtle invasion and its far-reaching 

o 



194 SYSTEM OF GYNECOLOGY 

effects, requires careful investigation. Of these effects sterility is the 
most important. When patients seek advice, many years after marriage, 
on account of barrenness, persistent leucorrhoea, menorrhagia, and dys- 
menorrhoea, symptoms all dating from the time of marriage, the possi- 
bility of gonorrhoeal infection must be kept in mind. Here also we note 
the importance of the etiological standpoint ; for if we can be sure of 
the cause, the whole case, as regards both diagnosis and treatment, 
assumes a different complexion. 

Uterine inflammation as the result of displacements is of interest, 
as it gives us the clue to the difference in the opinions of gynaecologists 
concerning the significance of these lesions. Where retroversion has 
not interfered with the involution of the uterus during the puerperium 
the displacement is symptomless; but if endometritis and chronic me- 
tritis be present, we have then symptoms due to these pathological 
conditions. Chronic metritis and endometritis are by no means such 
invariable accompaniments of retroversion as they are of prolapse, in 
which there is always some hypertrophy due to their presence. For 
the full discussion of the relation of displacement to inflammatory con- 
ditions, see the chapter of this work on " Displacements of the Uterus." 

Chronic metritis and endometritis also accompany fibroid tumours 
of the uterus and mucous polypi, as described in the chapter on " Simple 
Growths of the Uterus." 

We pass now to the various forms of inflammation, dividing them, 
according to the seat of the lesion, into (A) Cervical catarrh ; (B) Endo- 
metritis; and (C) Metritis. 

The cervix is sufficiently distinct from the body of the uterus to 
justify its being treated separately. Structurally it is quite different 
from the latter : on its vaginal aspect it is covered with squamous 
epithelium resting on papillae of connective tissue, and without mucous 
follicles ; its canal is lined with a single layer of cubical epithelium so 
folded as to form shallow recesses with racemose mucous glands ; its 
mucous surface differs, therefore, from that lining the body of the 
uterus. Its muscular tissue is not arranged in layers, but consists of 
fibres scattered irregularly through the connective tissue which prepon- 
derates. Functionally, it differs from the body in that it plays a passive 
part in menstruation and pregnancy. Pathologically, it differs in that 
the tumours which are common in it are rare in the body of the uterus, 
and conversely. We are therefore prepared for the fact that chronic 
inflammation of the cervix may not spread to the body of the uterus. 
Though clinically we frequently find cervicitis accompanied by inflam- 
mation of the body, yet the fact that this association does not by any 
means invariably occur warrants our considering the cervix by itself. 

An anatomical and pathological basis for classification of the various 
forms of uterine inflammation is preferable to a purely clinical one. As 
an illustration of the latter, we have Pozzi's classification according to 
"the dominant clinical characteristic." He thus describes (i.) Acute 
inflammatory metritis ; (ii.) Haemorrhagic metritis ; (iii.) Catarrhal me- 



INFLAMMATION OF THE UTERUS 195 

tritis ; (iv.) Chronic painful metritis. While agreeing with all that he 
says as to the artificial nature of the various classifications of varieties 
of uterine inflammation, and agreeing with him also on the importance 
of the clinical standpoint, we question whether merely to select a promi- 
nent symptom as the basis of classification, is an advance in our method 
of classification. Though much can be said in its favour, it is practi- 
cally to return to the symptomatological standpoint regarding disease. 

A. Chroxic Cervical Catarrh. — Acute cerWcal catarrh can sel- 
dom be studied as a separate condition. It occurs as part of the general 
inflammation of the uterus seen in puerperal sepsis, and is often the initial 
stage of the chronic affection, from which, however, it is not marked off. 

Chronic cervical catarrh is one of the most important conditions which 
the gynsecologist has to treat. Matthews Duncan said that, according to 
its gravity, it would not be placed higher than the third rank ; but that 
on account of its frequency it ranks with chronic ovaritis and chronic 
inflammation of the uterus. 

Clinical History and Symptoms. — The patient, usually a multipara, 
comes complaining of a weak back and '• whites." The pain is generally 
found to be in the sacral region, the seat of sympathetic pain for the cer- 
vix ; sometimes it is a sense of dragging or bearing down on the pelvis. 

The white discharge may simply be an exaggeration of the normal 
secretion of the cervix, which is viscid and opalescent, or it may be 
yellow and purulent. In the former case it is difiicult to draw the line 
between the normal and the morbid, as many women normally have a 
certain amount of leucorrhoeal discharge, especially after the menstrual 
period. The discharge may have probably lasted some time, unless 
suddenness of onset with urinary symptoms, which is often suggestive of a 
gonorrhoeal origin, lead her to seek advice at once. The most striking 
feature of cervical catarrh is its chronic character ; the condition is one 
which sometimes lasts for years. The patient may show one of the con- 
stitutional conditions referred to under etiology, such as anaemia or the 
gouty diathesis ; and the more remote causes leading to the congestion of 
the uterus, as of other organs, should always be inquired into. The 
symptoms will most frequentl}^ be traced back to child-birth or abortion, 
sometimes to exposure to cold or undue fatigue at a menstrual period, or 
to the commencement of gonorrhoeal infection. In acute cases urinary 
complications are often present. Menstruation is some times profuse and 
painful, which is probably due to accompanying endometritis — just as 
the pain in sexual intercourse, which is sometimes complained of, may 
be explained by associated parametritis ; the cervix uteri itself is not 
sensitive. If the condition have persisted for a long time symptoms of 
general weakness come on. The patient complains of lack of energy and 
of being easily tired, and she may have a poor appetite and slow 
digestion. Sterility is also present in some cases, although it is difficult 
to say whether this is due to a plug of mucus in the cervix or to some 
affection of the mucous membrane higher up in the genital tract. The 



196 SYSTEM OF GYNECOLOGY 

explanation of the sterility is more probably vital than mechanical, 
as the discharge affects the vitality of the spermatozoa. 

Pathology in Relation to Physical Signs. — Pathology renders a 
peculiar service to the clinician in giving him a basis for physical diag- 
nosis. It accounts for appearances which he has noticed clinically. The 
study of disease is the study of a life history. At each successive stage 
in its progress the pathologist steps in and gives a physical basis for each 
sign and symptom. He clears away the crumbling remnants of a broken- 
down hypothesis, and enables the clinician to put his foot down on the 
rock of anatomical fact. We consider pathology, therefore, in its relation 
to physical signs. 

Nowhere has this service of pathology been more strikingly illustrated 
than in the physical diagnosis of cervical catarrh. The use of the speculum 
to determine the source of the discharge shows a red granular surface 
round the os externum, which bleeds easily. Though more difficult to 
use, Sims' speculum is superior to either the bivalve or tubular one, 
because it disturbs less the normal condition of the parts, and enables us 
to judge of the presence of laceration and the amount of ectropion. 

The surface looks like an ulcer, because it is red, granular, and 
bleeds ; and looking like an ulcer it was called an ulcer, and treated by 
surgical methods as ulceration. Notions derived from ulceration of the 
skin were imported into the region round the os ; and herpes, pemphi- 
gus, varicose ulcers, and cockscomb granulations were described. The 
condition round the os was dissociated from the catarrhal inflamma- 
tion within the canal, or was regarded as secondary to it, the irritating 
leucorrhoea causing destruction of tissue. The term ulceration not only 
suggested a wrong treatment, but gave the condition an undue impor- 
tance in the mind of the patient. 

All this was changed by the microscopic work of Ruge and Ye it (30), 
who showed that the apparently raw surface is covered with epithelium, 
^is^ and that the granular points are new 

^ ^f ^ formations which have no relation to the 

I /f^K ^f^^^ granulations of an ulcer. The micro- 
' ' '.'''' scopic characters of the mucous mem- 

brane, to be readily understood from Fig. 
.; :i ' , , 44, which represents a clipping from one 

rf' i| ^ ' of these catarrhal patches, are as follows. 

^ '^ L The surface is covered with a single layer 

\^ f, of epithelium, the cells are smaller than 

'''^^'* those which line the normal cervical 

^ ,, ^ J'^-^--'-' canal, and being narrow and long, have 

Fig. 44. — Section of a catarrhal patch (so- / , ,., ^ ^ 

called ulcer) on the vajrinai aspect of a palisadc-like arrangement, ihe thin 

the cervix. The free surface is covered . ^ ^^| 2X\q^y^ the Subjaceut vaSCU- 

with a single layer of columnar epithe- -j _ J 

lium. It is folded into papillary eleva- lar tisSUC tO shiuC tlirOUgll, hcnCC the red 

tions. Below the surface are gland spaces j,.->v.pa^r,^pp ^.f fUp ^.^.f j.pp Thp c;nrfqpp 

cut across which may become dilated so appcaraucc 01 tue suiiacc. j_ne suriacc 

as to form retention-cysts. is further throwu iuto numcrous folds 

producing glandular recesses and processes. These processes cause the 



INFLAMMATION OF THE UTERUS 197 

granular appearance of the surface. If the recesses be long and narrow, 
the surface is split up into distinct papillae. This constitutes the papil- 
lary erosion. If the ducts of the glandular recesses become obliterated, 
the secretion distends the glands below and produces retention-cysts ; 
these increase in size, and may come to the surface and burst. Thus is 
formed the follicular erosion. 

The raw-looking surface is therefore a newly formed glandular 
secreting surface, which in structure resembles the cervical mucous 
membrane. This addition to the extent of secreting surface increases 
the leucorrhoeal discharge, which is the leading symptom. The so-called 
ulceration is thus seen to be simply a part of the process of cervical 
catarrh, and this not the most important part. If the cervix have been 
lacerated the swollen mucous membrane causes a gaping of the cervi- 
cal canal at the cleft ; and thus we may be misled as to the extent to 
which the catarrhal patches spread beyond the os externum. By roll- 
ing in the everted lips with the tenacula until the laceration closes we 
can estimate the probable position of the os externum. 

From this it is evident that the process is not one of ulceration, 
and the term should be abandoned. The German term "erosion" is 
open to similar objections. "Ectropion" or "eversion" of the mucous 
membrane describes the condition in its relation to laceration, but 
does not describe the extension of the secreting surface beyond the 
OS externum. The term is perferable to ulceration, however, as it is not 
so misleading. Thomas describes these conditions under the name 
of granular and cystic degeneration of the cervix uteri, and Palmer 
makes a compromise between the new and the old by treating of them 
under the title of " ulcerations and degenerations of the cervix uteri." 
We are not yet in a position to introduce a term based on pathology, 
even if it were desirable to give to this appearance a special name, and 
thus to suggest a difference in nature from the inflamed mucous mem- 
brane in the canal. Probably the best name for these red patches 
lying outside the os externum is "catarrhal patches," as it suggests 
that they are portions of the mucous membrane in the same catarrhal 
condition as that lining the cervical canal. 

Fischel and other observers have confirmed these observations of 
Euge and Veit in their essential points. Pischel considers, however, 
that the secreting processes, though new formations, have the structure 
of papillae, and are not mere foldings of the mucous membrane. 

While there is, therefore, no disagreement as to the microscopic 
appearance of the so-called " ulcerations," the origin of this new epithelial 
structure is disputed. Euge and Veit hold that this single layer of small 
cylindrical cells is produced by proliferation of the cells of the deepest 
layer of the rete Malpighi, while those of the superficial layer are shelled 
off. It will be observed also that they regard the simple follicula.r and 
papillary " ulcerations " as the results of one and the same process, 
namely, proliferation of epithelial cells. On the other hand, those red 
patches are generally continuous with the mucous membrane of the cer- 



SYSTEM OF GYNECOLOGY 



vical canal, and resemble it in their microscopic structure. It is therefore 
much more probable that they are occasioned by proliferation of the epi- 
thelium which lines the cervical glands, leading to an extension of the 
glandular surface beyond the os externum. Fischel holds that there 
is not only a proliferation of epithelial cells, but of connective tissue 
also, and that as the one or the other preponderates the follicular or 
papillary forms are produced. He also thinks that erosions are due to 
the persistence of the cylindrical epithelium (found outside the os 
externum in the foetus) into adult life, and to the desquamation of the 
squamous epithelium which had come to cover it. 

The question of the origin of the cylindrical epithelium found in 
erosions is rendered more difficult by the fact that the boundary-line 
between the squamous epithelium outside the cervical canal and the 
cylindrical within it varies at different periods of development and in 
different individuals. In the foetus, according to Euge's investigations, 
the cylindrical epithelium extends beyond the os externum ; and we have 
a hint of the persistence of this foetal condition in the congenital ectro- 
pion described by Fischel. Klotz describes two types of cervix distin- 
guished by the distribution of the squamous epithelium : one, cavernous 
in texture, and having the squamous epithelium extending some distance 
into the cervix ; the other, glandular in its substance, and having the 
squamous epithelium stopping at the usual seat of the os externum. 

The foregoing description is based on what is found in multiparous 
patients in whom the cervical changes, as seen through the speculum, are 
obvious. In nulliparous patients cervical catarrh may manifest itself 
by catarrhal patches beyond the os externum, but more frequently the 
vaginal aspect of the cervix, though soft and swollen, looks healthy. 
The mucous membrane within the canal, however, is in a similar con- 
dition to that described above. The os is sometimes unusually small, 
and the cervical canal becomes distended with the secretion. 

The diagnosis of cervical catarrh is comparatively easy, the cervix 
being accessible to examination. The condition found on vaginal examina- 
tion varies as the patient is a nullipara or a multipara. In the former case 
the cervix feels enlarged and softened, and when there is extension of the 
catarrhal area beyond the os externum the margins of the os are soft and 
velvety. In a multipara the os will probably be notched by old lacera- 
tions, and may be so patent that the tip of the finger can be passed into 
the cervical canal The area round the os is soft and velvety, or rough 
and granular ; and when the Nabothian follicles have been converted 
into retention cysts, these are felt as small nodules, like peas or shot, 
in the mucous membrane. Polypoidal projections may be present, and, 
more rarely, the whole cervix is converted into a cystic mass. The 
speculum can now be used to confirm what the fingers have felt, and 
is absolutely necessary in training the finger to recognise the various 
conditions present. The extent of catarrhal area, the amount of eversion, 
and the appearances corresponding to the velvety, granular, and nodular 
feelings are demonstrated by it. But once the finger has been educated, 



INFLAMMATION OF THE UTERUS 199 

the speculum, for diagnosis at any rate, comes to be less and less used. 
When it is desirable to determine the extent of lacerations with a view 
to operative procedure, tenacula are useful to roll in the everted lips 
of the cervix. The sound is only of service in diagnosing catarrh in 
nulliparae, where it may show a cervical canal unusually dilated by 
accumulated secretion. 

Under differential diagnosis we have only to consider the diagnosis of 
cervical from vaginal or uterine leucorrhoea, and of simple induration of 
the cervix from syphilitic ulceration and commencing malignant disease. 

The normal secretion from the glands of the cervical canal is clear and 
viscid, resembling unboiled white of ^gg ; and it is alkaline in reaction. 
It may be of an opaque white due to an escape of mucous corpuscles, or 
yellow when pus corpuscles are present. Frequently it is tinged with 
blood. In the worst cases of catarrh the discharge is a thin yellow or 
greenish pus. The diagnosis of cervical from vaginal leucorrhoea is made 
by the speculum, for in the former case we see the leucorrhoea, with the 
characters above mentioned, coming from the cervix ; or by Schultze's 
method of placing a tampon at the os externum to catch the cervical secre- 
tion. The diagnosis of cervical from uterine leucorrhoea is more difficult. 
Menorrhagia, with increase in the length of the uterine cavity and irregu- 
larities in its mucous membrane, point to the presence of endometritis. 

Syphilitic ulceration of the cervix is extremely rare, and the history, 
with the indications of syphilis in other parts, makes diagnosis easy. 
On the other hand, the diagnosis from commencing malignant disease 
is exceedingly difficult. If we are dealing with a case of advanced car- 
cinoma, in which ulceration has occurred, there is no difficulty; the 
finger at once recognises the friable bleeding surface Avith firmer mar- 
gins, and the infiltration of the cellular tissue causing fixation. If, how- 
ever, the cervix be simply nodular, and ulceration has not occurred, it 
may be impossible to say at this stage whether the case be one of cancer 
or not. Bennet drew attention to the fact that the lobulation of the 
cervix in chronic inflammation was more regular, the furrows radiating 
from the cervical canal being in fact old lacerations, while in cancer the 
lobulations are irregular. According to Spiegelberg, when a tent is 
placed in a cervix affected with malignant disease the infiltrated parts 
do not dilate like normal tissue. This subject belongs, however, to the 
diagnosis of commencing cancer, for which the chapter of this work on 
" Malignant Diseases of the Uterus " must be consulted. 

Treatment The importance of constitutional treatment must be 

fully recognised, as there is no doubt that far too much attention has 
been given to local treatment. In most essays on the treatment of cer- 
vical catarrh we find pages given to local applications and to operative 
procedure, while general treatment is dismissed in a paragraph. This 
makes the local, as against the general treatment, bulk far too largely in 
the mind of the practitioner. While, on the one hand, it may be argued 
that there will always be a class of patients who are not satisfied unless 
something is being done directly for them, we must remember that, on 



SYSTEM OF GYNECOLOGY 



the other hand, irreparable harm often results from lines of treatment 
which direct the patient's attention to the pelvic organs. 

The care of the patient's general health is to be put in the forefront. 
Change of air, light nourishing food, and a certain amount of exercise 
are beneficial ; and cold hip-baths in the morning are of service. Dis- 
turbances of the digestive system, which are frequent in chronic cases, 
must be carefully treated. Where rest from sexual activity is desirable, 
this is often secured by recommending that the patient leave home for 
a time. Tonics, such as arsenic, quinine, and iron, are useful. Sir James 
Simpson recommended arsenic, believing that it acted beneficially on the 
cervix as it does on skin eruptions. 

The diathesis should also be carefully studied. In strumous or gouty 
patients, for example, cervical catarrh is simply one of many manifesta- 
tions of the constitutional state, and is only of significance as directing 
our attention to it. 

Of local applications the most important is the vaginal douche. This 
treatment, as well as the mode of applying various therapeutic agents to 
the uterus, is described in the chapter on '' Gynaecological Therapeutics " ; 
so that here mention need be made only of special points bearing on their 
use in uterine inflammation. The douche, to be effective, should be given 
by means of a douche-can, and consist of not less than a quart of water. 
The patient should be semi-recumbent. The temperature of the water 
must be adapted to the individual case : if pain or haemorrhage be pres- 
ent the hot douche is preferable. The douche is given for cleanliness, 
and for the application of antiseptics and astringents. Corrosive subli- 
mate (1 to 4000) is very useful in chronic catarrh, especially if a gonor- 
rhoeal or septic taint be suspected. Sulphate of zinc (1 dr. to a pint), 
sulphate of alumina or sulphate of copper (2 drs. to a pint), are also 
beneficial. The action of these on the catarrhal patches has been 
specially investigated by Hofmeier, who found that the pale, squamous 
epithelium gradually crept in tongue-like processes over the red patch. 
Fig. 45 shows how the superficial glands become filled up with squamous 
epithelial cells. The deeper glands have their ducts narrowed or even 
plugged while the gland cavity persists below. Kiistner found similar 
changes produced by antiseptic douches. 

Medicaments may also be applied on vaginal tampons, the best 
excipient being glycerine. The glycerine itself acts by withdrawing 
serum from the engorged tissue. To it may be added boric acid (50 
per cent), tannin (1 dr. to 1 oz.), ichthyol (10 per cent), and iodoform. 

Applications may also be made on forceps dressed with cotton wad- 
ding, dry wadding being used first to swab off the mucus. Churchill 
used a preparation of iodine consisting of 75 grains of iodine and 90 of 
potassium iodide in 1 ounce of alcohol. Weak solutions of nitrate of 
silver are also beneficial. 

Where the cervix is much indurated and studded with retention- 
cysts, scarification is very useful ; it acts by depletion, and also by let- 
ting out the inspissated mucus. Bleeding by scarification has largely 



INFLAMMATION OF I'HF UTERUS 



taken tlie place of leeching. Various scarificators have been devised, 
but an ordinary bistoury does perfectly. A tepid douche given after- 
wards promotes bleeding. Scarification is preferable to tlie actual 
cautery, which has been recommended by Prochownik, as the latter is 
followed by cicatrisation. In very chronic cases the only remedy is to 
destroy the diseased glands, as we excise the tonsils in tonsillitis : this 
is done by caustics, the curette, or the knife. Of caustics, potassa-fusa 
was recommended by Sir James Simpson, and the zinc-alum sticks of 
Skoldberg by Matthews Duncan. This use of caustic must be distin- 
guished from the application of it to touch the so-called ulcer so as to 
make it heal, and has many advocates. It is better to use the curette, 
as recommended by Thomas, or the knife as in Schroeder's operation 
(32). In factj where the glandular tissue has to be destroyed, the most 



I 






^ i/^' 



■^; 






yt:niiaTl^ 



Fig. 45. — Healing- of a catarrhal patch treated by astrinpent or antiseptic injections (Hofnneier). From 
c to Z* is seen part of a catarrhal patch (compare Fig. 44) Avhich from h to a has become covered 
over with newly formed squamous epithelium ; dd, glands whose ducts have been obliterated ; 
c, gland duct which has persisted. 

efficient and cleanest way of doing it is by excision of the mucous mem- 
brane, although the cases in which this operation is called for are com- 
paratively rare. In Schroeder's operation the cervix is laid hold of by 
two volsellse, one on each lip, and drawn downwards. It is then divided 
laterally, as far as the fornix, with the scissors, so as to form an anterior 
and posterior lip which are separated as far as the vaginal roof. A trans- 
verse incision (seen in section at a, in Fig. 46) is made across the base of 
the anterior lip dividing the whole thickness of cervical mucous mem- 
brane. The point of the lip is next pierced at c, and the knife pushed 
in the direction hh till it reaches the cross incision a ; the blade is then 
carried outwards, first to the one side and then to the other, so that all 
outside of the line a, h, c is removed. The flap of the cervix is now 
turned in and stitched (Fig. 47), and the angles of the wound in the 
fornix closed. 

Emmet's operation is also useful in cases of deep laceration, espe- 



SYSTEM OF GYNAECOLOGY 



cially where there is cicatricial tissue at the base of the cleft : it has not 
fulfilled all that was expected of it, however, and it is not performed 
nearly so frequently as was the case some years ago. It simply conceals, 
without removing the diseased mucous membrane, and should always be 
combined with measures directed to the treatment of the catarrh. 

For marked hypertrophy of the substance of the cervix amputation 
is the only treatment. 

In the cervical catarrh of nulliparae, where there is a narrow os 
externum, the bilateral division of the cervix is of service. It allows 
the secretion to escape instead of accumulating ; and applications can 
be made to the cervical canal. It is also said to favour the occurrence 
of conception. 

These operations are described in the chapter on '' Plastic Gynaeco- 
logical Operations." 





Fig. 46. 



Fig. 47. 



Schroeder's operation for excision of the cervical mucous membrane in cervical catarrh. Fig. 46, 
line of incision in mucous membrane ; Fig. 47, mucous membrane excised, and flap he turned in 
on fl&. 



Acute Metritis and Endometritis. — In the acute condition we 
cannot separate these two affections. Clinically they are met with in 
the puerperal state, and as exacerbations of the chronic condition to be 
described presently. Except in the puerperal state they are never fatal, 
and hence the classical descriptions which are handed from text-book to 
text-book belong to a treatise on puerperal fever rather than to a system 
of gynaecology. 

Wyder (44), from a study of the membrane exfoliated in cases 
of membranous dysmenorrhoea, has recently described the pathological 
changes which he regards as those of acute endometritis. The cells in 
the stroma are greatly increased in numbers, and are so closely packed 
together that little of the matrix is seen. Gottschalk, on the other 
hand, finds in the exfoliated membrane changes characteristic of a 
haemorrhagic interstitial endometritis. Membranous dysmenorrhoea, or, 
as it has been called, exfoliative endometritis, is a rare affection, 



INFLAMMATION OF THE UTERUS 203 

and its pathology can hardly be considered to be the same as that of 
acute endometritis. 

B. Chronic Exdometritis. — This is a sufficiently well-marked con- 
dition to merit separate treatment. I Avould limit the term to those cases 
in which the patient has the general symptoms of chronic uterine inflam- 
mation, which I shall describe under chronic metritis, with in addition 
increased discharge either of blood at the menstrual period, or of leucor- 
rhoea in the intervals. As the presence of either of these symptoms 
points to changes in the uterine mucosa as the more prominent condition, 
there is sufficient reason for treating chronic endometritis as a condition 
distinct from chronic metritis. 

Clinical History and Symptoms. — The history may be traced back to 
abortion or labour, to an attack of uterine inflammation as the result 
of chill, or to gonorrhoeal infection. In a considerable number of cases, 
however, the symptoms begin insidiously, and develop gradually Avith- 
out any assignable cause. Endometritis is more frequent in muciparous 
patients, and more common later than earlier in life ; though it also 
occurs in nulliparae, especially when there is stenosis of the os externum. 
E-uge describes one-half of his cases as occurring after forty years of 
age (29). After the menopause a senile form of endometritis may 
appear, which has to do with the retrogressive changes taking place 
at that time in the uterus. 

The symptoms characteristic of endometritis are leucorrhoea and 
menorrhagia. The secretion from the body of the uterus is less viscid 
than that from the cervix, and may be clear ; but more frequently it is 
muco-parulent. It may be tinged with blood so that the patient believes 
herself to be more or less continually unwell. Sometimes it comes away 
more freely than at others, as if it collected in the uterus, or as if there 
were hypersecretion at intervals. It may be so irritating as to excoriate 
the vulva. 

Menorrhagia is generally present, but not always. In some cases the 
loss may be so considerable as to suggest malignant disease, and even to 
endanger the patient's life by profound ansemia. 

Of the exact relation of these symptoms to the anatomical changes to 
be immediately described, we do not yet know enough to make definite 
statements. Olshausen, who first described endometritis fungosa, — a 
state in which the changes are interstitial, — drew attention to haemor- 
rhage as the prominent symptom in these latter cases. Wyder also, who 
has studied the mucous membrane changes found with fibroid tumours, 
maintains that bleeding occurs in interstitial, but not in glandular 
endometritis. On the other hand, Veit holds that bleeding may occur 
with either variety. Whatever be the reason of the haemorrhage, this 
is the symptom which most immediately affects the patient's health and 
calls for prompt treatment. 

Pain at the menstrual period is sometimes present, although it is 
less frequent in endometritis than in inflammation of the uterine append- 



204 SYSTEM OF GYNAECOLOGY 

ages. It is, of course, characteristic of the exfoliative form. The weak 
back and other pains will be considered under chronic metritis. 

The reproductive function is liable to be affected, although it is sur- 
prising how many patients show all the symptoms of endometritis in 
the intervals between conception. Sterility is occasionally found, but it 
is difficult to say whether it be not due to associated inflammation of the 
uterine appendages, as undoubtedly is the case in gonorrhoeal infection. 
Definite information as to the effect of uterine secretions on the vitality 
of the spermatozoa is wanted. Cases in which conception after a period 
of sterility follows shortly on curetting, point to the fact that the 
diseased mucosa in some way prevents conception. Abortion is un- 
doubtedly often due to the morbid condition of the mucous membrane, 
which leads to haemorrhages into it, and to bad implantation or death 
of the ovum. 

Pathology in Relation to Physical Signs. — Pathology has here ren- 
dered service by explaining the conditions found by the sound and 
curette, the two instruments usually employed in the recognition of 
endometritis. 

The only changes in the uterus are the increase in the size of its 
cavity, and the swollen and soft condition of the mucous membrane. 
The latter, moreover, is sometimes thrown into rough projections, and is 
also so congested that it bleeds easily. All of these features are recog- 
nisable by careful use of the sound. In fact, it is for the exploration of 
the mucosa rather than for determining the position of the uterus, that 
we find the sound of service ; it shows that the cavity of the uterus is 
always enlarged in cases of endometritis. Rough granulations can be 
detected by holding the handle delicately ; and even the peculiar soft 
character of the thickened membrane may be thus recognised. If bleed- 
ing occurs after its use, congestion of the mucosa exists. It is also said 
that its introduction is accompanied with pain, and that areas painful 
to touch can be made out over the fundus (Eouth), or in other parts of the 
uterus (Veit). It is extremely difficult, however, to exclude peritonitic 
or cellulitic conditions which would also cause pain from the movement 
given to the uterus as the sound is introduced. 

The hypertrophied mucosa can be easily scraped away by the curette, 
and its microscopic examination by the pathologist has done much to 
clear up our conception of endometritis, although much has yet to be 
learned. Cornil, de Sinety, Heinricius, Kiistner, Olshausen, Euge, and 
Wyder have all made important contributions on the pathology of the 
changes of the endometrium in endometritis. Olshausen describes 
changes in what he calls endometritis fungosa, of which the leading 
symptom is haemorrhage. He found the mucosa hypertrophied to three 
or four times its normal thickness, and elevated throughout in a cushion- 
like swelling, or in discrete spongy masses. The change stops at the 
OS internum, and does not affect the cervix. The portions removed by 
the curette show, on microscopic examination, great "hypertrophy of 
the mucosa, with increase of all its elements, moderate dilatation of the 



INFLAMMATION OF THE UTERUS 



205 



uterine glands, enlargement of the blood-vessels, and marked cellular 
infiltration of the connective tissue.*" The glands are not enlarged so 
as to produce cystic dilatations. 

De Sinety describes three forms of vegetations removed by the 
curette. In one the tissue consists mostly of dilated blood-vessels ; in 
another of dilated hypertrophied glands ; in a third of embryonic 
tissue, with but few blood-vessels and only traces of glands. These 
three forms of granulations he associates with the three kinds of dis- 
charge — sanguineous, leuchorrhoeal, and muco-purulent. 

Ruge (29) describes three forms — "the glandular, the interstitial, 
and the mixed." In the glandular a section shows that the glands, 
instead of running more or less straight downwards, are cut across in 
all directions. Their appearance on section varies as the glands have 
changed their direction, or their epithelium has been altered, star-like 
and saw-like figures being produced. Sometimes they are dilated into 
cysts. In the interstitial form the stroma is filled with small round cells, 
and the vessels are dilated and tortuous ; but the glands are not affected. 
The mixed form is a combination of the other two. The glandular occurs 
in more advanced life ; the interstitial at all periods. 

Wyder (44) has studied the changes in the mucous membrane in endo- 
metritis accompanying fibroid tumours. He describes Ruge's glandular 
form as principally accompanying subserous fibroids, and not having 
haemorrhage as a symptom. In the interstitial variety, in which haemor- 
rhage is prominent, the glands are constricted at various points and 
transformed into cysts ; or they are compressed and atrophied. As the 
result of this the glands are few in number. The interglandular tissue 
is marked by the abundance of its vessels : it appears in parts as a tissue 
rich in spindle cells with processes which give it a striated appearance ; 
in other parts it is transformed into a fibrous tissue with few cells. The 
constricted glands may appear as clear, transparent vesicles, projecting 
above the surface of the membrane. The cicatrisation of the connective 
tissue compresses the vessels and leads to haemorrhage. The process 
may go on till all the glands have disappeared, and the mucous coat is 
represented by a homogeneous connective tissue, wavy in outline, which 
may be covered by a layer of epithelium. When the dilated cystic glands 
form distinct projections on the surface we have a polypoidal glandular 
endometritis, which passes insensibly into mucous polypi. 

Cornil in his lectures on metritis gives a very complete account 
of the appearance of the mucous membrane. Its surface is fungoid 
instead of smooth, and shows villous projections and cysts the size of a 
pin-head. On section it is 2 to 10 mm. thick — instead of 1 mm. as in 
the normal condition. The glands are more tortuous; and, what is un- 
like a non-malignant condition, have grown beyond the usual limit into 
the muscular wall. The glandular cells, though chronically inflamed, 
retain their cilia. The layer of flat cells separating them from the inter- 
sjlandular tissue is also undisturbed, which is of importance in diagnosing 
it from epithelial cancer. That it is a true inflammatory change is seen 



2o6 SYSTEM OF GYNECOLOGY 

from the excess of mucus, the multiplication of epithelium, and the 
migration of leucocytes. Mucous plugs may be seen, recalling the hya- 
line casts of albuminuria. Karyo-kinesis can often be observed in the 
gland cells. Lymphoid cells are found in the gland cavities which have 
escaped from the capillaries and passed through the gland cells. The 
interglandular tissue shows dilatation of its vessels and infiltration with 
wandering lymphoid cells, while the closely packed ovoid cells, of which 
it is normally composed, swell up and become spherical. 

Heinricius has also described specimens taken from cases of endome- 
tritis fungosa. He finds the stroma between the glands to consist of 
a basis of stellate corpuscles, with anastomosing processes, upon and 
between which lie two varieties of cells — some large, oval, and faintly 
stained ; others small, round, and deeply stained. The former are the 
nuclei of an endothelium, the latter are lymph corpuscles. His descrip- 
tion of the interstitial tissue makes it consist, then, chiefly of lymph 
sinuses. As the result of the inflammation, the lymph corpuscles and 
those of the endothelium proliferate and produce an appearance which 
resembles a small-celled infiltration, as the basis of the network is 
obscured by the cells. Thus he differs from other observers in regard- 
ing the small cells as occupying lymph spaces. 

Relation of Micro-organisms to Endometritis. — We have already re- 
ferred to this matter in speaking of the etiology of uterine inflammation ; 
but it is especially in connection with the pathology of the endometrium 
that the subject comes up for consideration. While attention is being 
directed more and more to the part played by micro-organisms in inflam- 
mation of the uterus, and too much stress cannot be laid on the germ- 
theory in so far as it leads to rigorous antisepsis in practice, the question 
is naturally asked. What direct proof is there of the part played by 
micro-organisms in endometritis ? It can only be answered from obser- 
vations made directly on the endometrium. 

As an illustration of the importance attached to micro-organisms, we 
may take the most recent classification of the varieties of endometritis 
given by Winckel, who arranges them in two groups, as they are due 
to micro-organisms or not. In the latter group he places — i. Simple 
catarrh due to disturbance of circulation, as in chlorosis, uterine displace- 
ments, faults in dress, mode of life, etc. : ii. HmmorrhagUz endometritis, as 
in acute and infectious diseases : iii. Decidual endometritis after abortion ; 
and iv. Exfoliative endometritis. In the former group he places — v. 
Gonorrlioeal endometritis: vi. Tubercular endometritis: vii. Puerperal 
septic endometritis, usually due to the streptococcus longus, more rarely 
to a staphylococcus or to the bacterium coli commune : viii. Saprophytic 
endometritis, due to combination of cocci and bacilli, of which the senile 
purulent endometritis is probably one form : ix. The so-called diphtheritic 
endometritis which is due to streptococci: x. Syphilitic endometritis — the 
cervical mucous membrane exposed by laceration being a favourable 
nidus, but infection of the decidua the more important cause : xi. Endo- 
metritis due to fungi, the yeast plant having been cultivated from the 



INFLAMMATION OF THE UTERUS 207 

secretion; and xii. Endometritis due to amoehce — protoplasmic bodies 
with, nuclei and vacuoles being present in the dilated uterine glands, 
and causing proliferation of epithelium. 

Such a classification suggests that micro-organisms are very important 
factors in the changes. At the same meeting, however, of the German 
Gynaecological Association, Bumm gave the results of the direct exami- 
nation of the secretions from forty-live cases of endometritis in the living 
subject ; and he concludes that the affection of the mucous membrane is 
not kept up by micro-organisms, and that their presence is accidental, 
and varies with the character of the secretions. He adds, however, that 
the supposition that chronic endometritis has nothing to do with micro- 
organisms is not incompatible with the fact that it may be the result of 
a septic or gonorrhoeal infection. So also Gottschalk and Immerwahr, 
after examining sixty cases of all forms of endometritis, found micro- 
organisms in the secretions of only one-half of them ; and to these they 
could not attribute a pathogenetic importance, although catarrhal inflam- 
mation might be attributed to their agency. 

The mucous membrane has also been examined in portions of the 
uterus removed at operations ; and I have already referred to Winter's 
results, which, however, w^ere not made specially on cases of endome- 
tritis. Menge has examined the mucous membrane from seventy-three 
specimens, including all forms of endometritis, and concludes that neither 
in the secretion nor in the mucous membrane are micro-organisms present, 
with the exception of the gonococcus and the bacillus tuberculosis. Fur- 
ther observations upon this subject must be w^aited for ; but for the pres- 
ent we may assume that micro-organisms play a subordinate part in 
chronic endometritis. 

The observations of Pfannenstiel, Doderlein, Gonner, and others on 
the lochia in the puerperium show the importance of the streptococcus 
in puerperal sepsis ; but this subject belongs to obstetrics rather than to 
gynaecology. 

The diagnosis of endometritis before the days of the curette w^as 
often uncertain. Haemorrhage may be due simply to congestion, with- 
out permanent changes in the mucous membrane ; and some enlargement 
of the uterus often persists after delivery. Unless the uterus be curetted, 
and the morbid condition of the endometrium demonstrated, our treat- 
ment is still often empirical. We may satisfy ourselves that there is no 
cause outside the uterus to account for the haemorrhage or leucorrhoea, 
and, finding the uterus enlarged, we may assume that endometritis 
is present. Where it can be traced back distinctly to abortion, diagnosis 
is more certain. 

Of the use of the curette for diagnosis the following illustrations will 
serve : — Figs. 48 and 49 are sections of scrapings taken from a case of 
interstitial endometritis — the endometritis fungosa of Olshausen. The 
patient Avas a multipara in whom profuse menorrhagia dated from her 
last confinement. She was curetted on two occasions, as the haemorrhage 
recurred after the first curetting. Since the last curetting her menstrual 



208 



SYSTEM OF GYNECOLOGY 



periods have been normal for some time. The sections show small-celled 
infiltration in the interglandular tissue, but no hyperplasia of the glands. 





iMG. 46. 

Section of tissue removed by curette from a case of interstitial endometritis. Fig. 48 shows the glands 
and interglandular tissue under a low power; Fig. 49, the same under a high power, to show the 
small-celled infiltration. 



The section given in Fig. 50 was taken from another case in which 
the endometritis was of the glandular type. The patient, a nullipara, 
has for five years suffered from considerable haemorrhages, and has been 
curetted on different occasions during this period without the benefit seen 
in the former case. The portions removed by the curette on the last 
occasion showed marked hyperplasia of the glands, with proliferation of 
^ the glandular epithelium, as is well 

seen in the portions of the glands 
shown in Eig. 50. Though the uterus 
is enlarged there is no infiltration 
round it; but from the proliferation 
of epithelium the case may in the 
end prove to be one of commencing 
cancer of the endometrium ; mean- 
while, therefore, the prognosis must 
be guarded. 

The curette has thus come to be 
of great value in the recognition of en- 
undergoing multiplication. TMs may pass domctritis, and of the various changes 

mto a malignant affection. . ' ^ 

present m the mucous membrane. 
Its use, however, is primarily for treatment, except where commenc- 
ing malignant disease is suspected ; and even here, where as a diag- 
nostic means it might be of most value, it often fails us. The portions 
of tissue removed are too small to enable us to form a definite conclu- 
sion as to the presence or absence of malignant disease. In some 
cases the malignant cells may be too characteristic for doubt ; but 




Fk;. 50. — Section of the glands from a case of 
glandular endometritis. The epithelium is 



INFLAMMATION OF THE UTERUS 209 

ill tlie majority of cases in which. I have used the curette for this purpose, 
the appearance of the tissue, if " suspicious," has not amounted to a 
demonstration. This subject, however, belongs to the diagnosis of com- 
mencing malignant disease, which is treated elsewhere. 

Treatment. — The constitutional treatment of endometritis will be 
discussed under chronic metritis. The local treatment consists in appli- 
cations made to the uterine mucous membrane, with or without previous 
curetting. Before having recourse to local applications w^e should be 
satisfied of the necessity for them. As in the case of cervical catarrh, 
local treatment has received undue attention. Vaginal injections, ergo tine, 
and other uterine haemostatics should always have a fair trial in the first 
instance. 

Applications are made in the solid or liquid form ; the latter, 
either by means of injection or on a sound dressed with cotton wadding. 
The technique of intra-uterine medication is fully described in the chapter 
on " Gynaecological Therapeutics." Here we have to consider it only as 
applied specially to endometritis. With regard to the methods mentioned, 
I may say that I believe only in the latter; the introduction of the 
caustic in solid form, so as to melt inside the uterus, is too indefinite in 
its action. The use of intra-uterine injections has not found favour in 
British gynaecology owing to the dangers connected with them. I do not, 
of course, refer to the w^ashing out of the uterus with Fritsch's catheter 
as part of the operation of curetting, but to the injection of caustics by 
special syringes, such, for example, as Braun's. Lantos' syringe, 
in which the point is wrapped in cotton wadding, into which the fluid 
exudes through holes at the side, is a safe instrument; but it does not 
possess any decided advantage over a dressed sound. I prefer to make 
applications with the ordinary sound dressed with cotton wadding ; the 
only objection to it being that the fluid is liable to be squeezed out of the 
wadding as it is carried through the os. This difficulty can be got over 
by using a thin film of wadding, by making more than one application, 
and by preliminary dilatation of a narrow cervix. It is always well to 
use a dry sound first in order to swab away the mucus, so as to allow the 
medicament to act. The applications I prefer are iodine, iodised phenol 
(consisting of 40 grains iodine in one ounce of carbolic acid), and pure 
carbolic acid prepared by liquefying the crystals. This mode of intra- 
uterine application has been recommended by Dr. Playfair, who has 
devised a special probe for it. 

Dr. Atthill advocates the use of strong nitric acid, and the preliminary 
dilatation of the cervix so as to allow of its free application. He uses an 
intra-uterine speculum of vulcanite to prevent the acid from acting on the 
cervical canal. Dr. Barnes has devised an ointment-positor for intro- 
ducing ointments or fluids. He applies the iodide of mercury ointment by 
this means, or tincture of iodine on a sponge. Munde uses a 20 per cent 
solution of chloride of zinc in the manner described above ; he recom- 
mends also pencils containing 5 grs. of powdered alum and of iodoform, 
which are left to melt in the uterus. 



3IO SYSTEM OF GYNAECOLOGY 

The best results from intra-uterine medication are obtained when it 
is applied after previous curetting. It is difficult to define the limits of 
this operation, but it is perfectly safe, and I have never seen any bad 
results after it. For this very reason it is liable to be abused, and to be 
performed in cases where it is not called for. The fact that the uterine 
mucosa can be so easily removed, and is so rapidly regenerated, is no 
argument for its removal; and the notion of a substitution of new 
mucosa free from germs, under aseptic conditions maintained for several 
weeks by the use of intra-uterine injections, is ingenious but open to 
doubt. 

I would limit the operation of curetting to cases in which there is a 
clear history of recent abortion, in which there is considerable menorrhagia 
which has not yielded to ergotine, or in which the sound shows the cavity 
to be distinctly enlarged and roughened with vegetations. It is not 
called for in cases of catarrhal endometritis, and of course should not be 
performed when there is acute or subacute inflammation of the uterine 
adnexa. Curetting for the endometritis of fibroids, and for the diagnosis 
of malignant disease, does not belong to the subject we are considering. 
The mode of performing the operation is described elsewhere. After it 
is done the uterus is to be washed out with a weak antiseptic, and the 
other applications then made as mentioned above. Where distinct por- 
tions of tissue are removed, they should be preserved for microscopic 
examination. 

Electricity has also been used to check the haemorrhage in endome- 
tritis. As it acts simply by cauterisation of the uterine cavity it does 
not present any advantages over curetting. It is of service, however, 
in the endometritis of fibroid tumours, where, in certain cases, it has an 
effect also on the growth of the tumour. 

C. Chronic Metritis. — As in the case of endometritis, I do not con- 
sider acute metritis deserving of separate consideration ; it appears in 
most treatises by reason only of the artificial division of affections generally 
into acute and chronic. The description of its pathology and treatment 
is taken from cases of puerperal inflammation which do not concern us 
here. We have good authority for discarding it as a separate affection, 
when Klob states that he has not met with a single case ; Rokitansky, that 
the uterine tissue is scarcely ever affected primarily ; Schroeder, that it is 
extremely rare ; while Thomas regards it as but a complication of endo- 
metritis. Sir William Priestley's description of it, in his admirable article 
in Keynolds' System of Medicine, is taken from puerperal sepsis ; and in 
the non-pregnant condition he describes it as occurring chiefly after opera- 
tions. The use of antiseptics in vaginal operations during the last twenty 
years, since his article was written, has lessened the frequency of such 
cases. In the American System of Gyncecology Palmer says that pure 
and uncomplicated metritis rarely if ever occurs. 

Acute metritis does occur as an exacerbation of the chronic condition, 
especially in connection with the congestion at the menstrual period, yet 



INFLAMMATION OF THF UTERUS 211 

here the chronic affection is more important. We may note also, in 
passing, the great rarity of suppuration in the uterine wall ; most of the 
cases thus described were abscesses in the cellular tissue beside the 
uterus. 

With regard to the frequency of chronic metritis there is a difference 
of opinion ; but it is largely a question of terms. In the present state of 
our knowledge we are disposed to relegate to chronic metritis all cases 
of chronic uterine inflammation which do not come distinctly under the 
category of chronic cervical catarrh, or chronic endometritis. In doing 
this we make chronic metritis one of the most important of the in- 
flammatory conditions of the uterus. It may be argued that our 
ignorance of its pathology, and the dif&culty of exactness in its diagnosis, 
are not a sufiicient reason for making it include a large group of cases of 
chronic invalidism which cannot be classified under the better known 
affections. For the present, however, this seems the best course for us 
to take. Under chronic metritis we include those cases which Sir James 
Simpson described under subinvolution (20), a term which, however aptly, 
only describes the conditions under which chronic metritis most fre- 
quently arises. 

Clinical History and Symptoms. — No better description could be 
given of the general features of cases of this class than that of Eennet; 
although he made the inflammatory condition of the cervix, rather than 
the accompanying condition of the body of the uterus, the important 
factor. " To this class belong a large proportion of the population of 
sofa, bath-chair, nervous, debilitated, dyspeptic females, who wander 
from one medical man to another, and who crowd our watering-places in 
summer ; most of them are suffering from chronic uterine inflammatory 
disease unrecognised and untreated, and most of them would, if their 
disease were only discovered and cured, become amenable to the resources 
of our art, and eventually recover their health, spirits, and powers of 
locomotion. It is a singular and instructive fact that amongst the male 
part of the community there is no similar invalid population, always ill, 
unable to walk or ride, constantly requiring medical advice, and yet living 
on from year to year, neither their friends nor themselves knowing what 
is amiss with them, beyond the evident weakness, dyspepsia, etc." (2). 

The symptoms, also, which Gooch ascribes to the irritable uterus we 
now attribute to chronic metritis. " To embody them in one view, let 
the reader fancy to himself a young or middle-aged woman, somewhat 
reduced in flesh and health, almost living on her sofa for months, or even 
years, from a constant pain in the uterus, which renders her unable to 
sit up or take exercise; the uterus, on examination, is unchanged in 
structure, but exquisitely tender ; even in the recumbent posture, always 
in pain, but subject to great aggravations more or less frequent." He 
thus describes exacerbations which are characteristic: — "No disease, 
however, is so liable to relapse. The patient, feeling easy, finding her- 
self feeble, and supposing that air and exercise are necessary to t>f^ 
recovery of her health, rises and goes about again, and after a short 



SYSTEM OF GYNECOLOGY 



interval of caution, throws aside her fears, engages in walks, rides, and 
gaiety, or takes a journey to the sea for the recovery of her health. This 
conduct commonly occasions a complete relapse, and the patient and her 
attendant are again involved in the former suffering, apprehensions, and 
difficulties" (13). 

It may be said that some of the cases described by Gooch were 
cases of affections of the Fallopian tribes, which were not recognised at 
the time at which he wrote. The line of treatment, however, adopted 
and the improvement under it shows that we are justified in considering 
them as cases of chronic metritis. Gooch's reason for not calling the 
condition a chronic inflammation — namely, that the latter is a dis- 
organising process, while the irritable uterus shows no alteration in 
structure — proves, on the contrary, that his cases were just what we 
would now describe as chronic metritis, the results of which tend to be 
permanent. 

The most constant symptom is pain in the lower part of the abdomen 
and in the loins. Sometimes it is spoken of as fulness or weight in the 
pelvis, or bearing down. In one word, as Pozzi puts it, the patient 
knows that she has a uterus. The pain is worst when she is going about, 
and relieved when she lies down. In this respect it differs from the 
pain of cancer, which is independent of exertion, and is often described 
as worse when she is resting at night ; probably because there is less to 
distract her attention from it. Whatever increases abdominal pressure 
and tends to move the sensitive uterus produces pain. Well-to-do 
patients, who can take relief by lying on the sofa, gradually come to 
spend most of their time there. 

The fact that the pain is aggravated by movement, and relieved by 
rest, raises the question whether the cause of it be not sensitiveness in 
the attachments of the uterus, rather than in the organ itself ; whether it 
be not an associated parametritis or perimetritis ? In many cases, how- 
ever, we cannot find evidence of these affections. If I were to draw a 
fine distinction I should say, that when pain is aggravated by movement 
of the uterus — as may be demonstrated on bimanual examination, or 
the use of the sound — rather than by simple pressure in the iliac regions, 
the lesion is chronic metritis, not perimetritis. We cannot always be sure 
that painful cicatrisation in the broad or utero-sacral ligaments is absent. 
The pain is often more marked in the left iliac region, which may in- 
dicate cicatrisation in the left broad ligament ; as most cases of chronic 
metritis date from the puerperal condition, in which left-sided cellulitis is 
more frequent because of the greater frequency of left-sided lacerations 
of the cervix. Pozzi ascribes this pain to inflammation of the left 
Fallopian tube, though he can give no reason why the left tube should 
be affected rather than the right. The pain, moreover, is increased by 
the congestion of the menstrual period, an increase which is ascribed to 
the flushing of the painful uterus with blood. Sometimes, however, 
patients are relieved by the menstrual flow, as by a local depletion. 

Neuralgic pains are frequent, though it is difficult to say whether 



INFLAMMATION OF THE UTERUS 213 

these are due to a source of irritation in the uterus, or to the general 
" run-down " condition of the system. The disturbances of digestion may 
more justly be regarded as reflex neuroses — such as the gastric dis- 
turbances of pregnancy, which depend upon the close relation between 
the uterus and the digestive system. The constipation, wdiich is a con- 
stant complaint, results probably from the want of exercise ; but sometimes 
it is due to shrinking from the pain of defaecation. In the acute exacerba- 
tions, indeed, there may be diarrhoea with tenesmus, due to extension of 
inflammation to the rectum; as there may be frequent and painful 
micturition from the extension of inflammation to the bladder. 

Disturbances of menstruation are often given as symptoms of chronic 
metritis. Painful menstruation is certainly one of them, and is accounted 
for by the congestion of a tender uterus. Profuse menstruation should, 
however, be referred to an accompanying endometritis ; though Fritsch 
thinks the connective-tissue formation in the wall affects the contractile 
power of the uterus, which he considers one of the factors which regulate 
the amount of the menstrual loss. This distinction is not a refinement, 
but bears on treatment ; for such cases can be treated by curetting, which 
we do not consider to be applicable to metritis. The possibility of the 
haemorrhage being due to an associated salpingitis, which has its own 
appropriate treatment, should also be borne in mind. 

The disturbances of the reproductive function (sterility and abortion) 
are also to be accounted for by the accompanying endometritis. 

The general effect on the patient's nervous system is perhaps the 
most important of all the consequences of this malady, and shows itself 
in asthenia and hysteria. It is extremely difficult to say how far these 
elements enter into individual cases, but an accurate appreciation of the 
proportion between the general and the local factors in these very complex 
cases is of the first importance when treatment has to be considered. By 
asthenia we mean the real loss of energy, which can only be made up by 
such a line of treatment as the Weir Mitchell. [See the section on " The 
Nervous System in Kelation to Gynaecology."] Hysteria, of which the 
treatment is rather a mental and moral regime, is also an important 
element in the malady. It is only by taking into account the condition 
of the central nervous system that we can explain the great variability 
in the amount and seat of the pain in chronic metritis, the sudden im- 
provements and relapses, and those cures in which the result bears no 
proportion to the means employed. 

Pathology in Relation to Physical Signs. — Still less is known of the 
pathological changes in chronic metritis than in endometritis or cervical 
catarrh. We have seen that the accessibility of the cervix to microscopic 
examination in the living subject has, during the last twenty years, given 
precision to our knowledge of its pathology, and that the curette is 
performing a like service for the endometrium in enabling us to study 
its pathological changes during life. An opportunity, however, for 
examining the condition of the wall is only given in the rare cases of 
extirpation of the uterus. 



214 



SYSTEM OF GYNECOLOGY 



Scanzoni's classical monograph, on chronic metritis deals entirely with 
the naked-eye characters. 

The microscopic changes have been described by De Sinety, Eritsch, 
and Cornil, but further observations are needed. 

Scanzoni describes two stages, — an early stage in which the uterus 
is enlarged, hypersemic, and soft, and a later one in which it is indurated, 
anaemic, and hard. Clinically it is impossible to distinguish two such 
stages : sometimes we find a soft uterus, and sometimes a firm one ; but 
no clinical observations have demonstrated that the one condition follows 
the other in the same patient. Scanzoni's description is the result more 




mM- 



tnU 



mU 



Fig. 51. — Section of the uterine tissue in a case of chronic metritis: c^, connective tissue round the 
blood-vessels, &-« ; Zs, dilated lymphatic spaces; «?/, ?, muscular fibre cut longitudinally; mj\ t, 
muscular fibre cut transversel}^ (De Sinety). 

of logical deduction from what we know of pathological changes in other 
organs than of direct study of the uterus. 

De Sinety follows Scanzoni in describing two stages. The first is 
characterised by " the presence in great number of embryonic elements 
throughout the whole thickness of the muscular wall. These elements 
are met with specially round the blood-vessels, or form islands of variable 
dimensions which are more or less apart." In the second stage he 
describes marked dilatation of the lymphatic spaces, and a localised 
hyperplasia of the connective tissue round the blood-vessels. Fig. 51 
is a section of the uterine tissue from one case which he examined. 

Fritsch's observations were made on uteri which, extirpated for 
cancer, also showed the naked-eye appearances of chronic metritis. He 
found that the disposition of muscular fibre and connective tissue is less 



INFLAMMATION OF THE UTERUS 215 

regular tlian in the normal nterns, tlie individual muscular bundles being 
split up into small irregular ones. The connective tissue is greatly 
increased in amount, and its bundles show remarkable bulging and 
undulations in tlieir course. Areas of normal tissue may be found in the 
same uterus, showing that chronic metritis may occur in patches. The 
blood-vessels are more numerous and tortuous, and thus in places pro- 
duce the appearance of a cavernous tissue ; their walls are thickened, 
especially in the middle coat; the contour of the vessel is masked by a 
connective tissue replacing the muscular elements in the wall, and the 
lumen of the vessel is often diminished. The lymphatics appear as 
gaping spaces instead of narrow clefts. The peritoneum is also thickened. 
Fritsch holds that the multiparous uterus must always be richer in con- 
nective tissue than the nulliparous ; seeing that where the special tissues 
are destroyed by inflammation connective tissue takes their place, and 
that few multiparse have not had inflammation in the puerperium. 

Cornil also describes, in cases of chronic metritis independent of 
parturition, a new formation of connective tissue between the muscular 
libres ; in the tissue opaque points are seen, which represent arteries 
undergoing atheromatous degeneration. Their walls are thickened by 
elastic tissue. There is no cicatricial contraction of this connective tissue, 
but a permanent increase in volume. 

It is not necessary here to recapitulate the views advanced under the 
head of pathology in the works of other writers on chronic metritis ; 
these opinions resolve themselves into a discussion of the meaning of 
chronic inflammation, instead of giving pathological data for determining 
the features of the changes in the uterus. The observations of De Sinety, 
Fritsch, and Cornil go to show that the essential change in chronic 
metritis is increase of connective tissue in the uterus. It is, therefore, 
somewhat analogous to that which occurs in fibroid tumour, save that 
the connective tissue formation is diffused through the uterus instead of 
being localised in masses. 

Thus pathology is the key to the physical signs. The uterus is enlarged 
throughout : there is no alteration in its form ; its consistence may be 
either firm or yielding. This equable enlargement of the uterus can be 
made out by careful bimanual examination and confirmed if necessary by 
the use of the sound. 

Diagnosis. — The conditions which are most likely to be mistaken for 
chronic metritis are enlargement of the uterus from commencing preg- 
nancy, small fibroid tumours, and malignant disease. 

In the case of early pregnancy, amenorrhoea and other symptoms 
should put us on our guard. The cervix is softened, although this 
softening is not so well marked in a multipara where the cervix has been 
previously indurated b}^ chronic inflammation : the bimanual examination 
shows the change in the form of the uterus due to growth of the ovum. 
In chronic metritis there is no alteration in the shape of the uterus, but in 
pregnancy there is a globular enlargement : the vaginal finger recognises 
the anterior wall bulging out from the cervix while the abdominal hand 



2i6 SYSTEM OF GYNECOLOGY 

feels the rounding out of the fundus, combined with a softness which 
prevents us from distinctly defining its outline. Where resistance of the 
abdominal walls makes the bimanual examination difficult, the finger may 
be able to recognise through the rectum the bulging and softness of the 
posterior uterine wall in contrast with the thin and compressible lower 
uterine segment. Pregnancy can be detected by careful bimanual ex- 
amination as early as the eighth week. Where there is any doubt, by 
waiting a few weeks the diagnosis from chronic metritis becomes easy. 

Small fibroid tumours closely simulate chronic metritis. The symp- 
toms are the same ; and on bimanual examination it is often extremely 
difiicult to distinguish the uneven enlargement of a fibroid from the uni- 
form enlargement of chronic metritis. By passing the sound so as to de- 
fine the course of the uterine canal and the position of the fundus, and 
then making a careful bimanual examination with the sound in position, 
we are able to detect small fibroids of the anterior or posterior wall. Intra- 
uterine fibrous polypi can only be recognised by dilating the cervix. 

While the diagnosis of chronic metritis from small fibroids is often 
of little moment, the diagnosis from early malignant disease is of great 
consequence. The age of the patient, the character of the pain, and the 
nature of the discharge, must all be taken into account. Free bleeding is 
also more suggestive of malignant disease, especially after the meno- 
pause ; although I have seen patients with fungous endometritis and 
chronic metritis lose a considerable amount of blood. In doubtful cases 
the cervix should be dilated so as to allow the endometrium to be care- 
fully examined with the finger or curette. 

Treatment rests upon pathology ; and the view we take of the nature 
and etiology of chronic metritis determines our treatment. The patho- 
logical facts, so far as we know them, are that the lesion consists in an 
increased formation of connective tissue in the uterus, and that the most 
favourable circumstances for its development occur during the puerperium. 

Sir James Simpson rendered a great service by calling it "sub- 
involution," thus drawing attention to the importance of the puerperal 
state in connection with its etiology. The best treatment is preventive ; 
and the removal of whatsoever interferes with the involution of the uterus, 
is to be put in the forefront in the treatment of chronic metritis. At- 
tention to the complete emptying of the uterus after delivery, and early 
removal by curetting of portions retained after abortion, are of the first 
importance. To stimulate the involution of the uterus by douching dur- 
ing the puerperium, to administer ergot, to order sufiicient rest, and to 
forbid patients to return too soon to their ordinary duties, are measures 
of preventive treatment which cannot be overrated in importance. 

Fortunately patients with chronic metritis are not often sterile ; and 
it is to the proper management of a subsequent puerperium that we must 
look for the treatment of this condition. The natural cure that then 
takes place is the only efiicient one. 

On passing now from preventive treatment to the general treatment 
of metritis, we shall find that to describe the treatment recommended by 



INFLAMMATION OF THE UTERUS 217 

the various writers on this subject would be simply to recapitulate all the 
resources of gynaecological therapeutics. Thus is revealed the impor- 
tance of the lesion, inasmuch as all the means at our command have been 
employed in dealing with it, and with more or less success ; yet variety 
of treatment generally means ignorance of the nature of the disease : as 
our knowledge grows our treatment is simplified. 

The main object of local treatment is to diminish passive congestion 
of the pelvic organs ; and here again the first indication is rest. Con- 
tinuous rest, however, is bad, for it favours congestion ; daily exercise in 
the open air is as necessary as an hour or two of rest on the sofa in the 
middle of the day. Tight garments which compress the abdomen should 
be discarded ; on the other hand, where the abdominal muscles are flabb}'. 
a well-adjusted abdominal belt often makes the patient more comfortable. 
Lax abdominal muscles are occasionally associated with a relaxed vagina 
and a tendency to prolaj^se : in such cases a ring pessary to support the 
heavy uterus is useful. 

To stimulate the pelvic circulation the hot douche is invaluable. It 
should be administered freely in the recumbent posture, and, if possible, 
by a trained nurse. It is of little value unless it is done thoroughly. 

Preparations of ergot also lessen uterine congestion. It is in the 
puerperium that we expect the most permanent benefit from this drug, 
on account of its action on the muscular fibres of the uterus, promoting 
their contractions and favouring their involution. Ergot is also useful in 
other circumstances, especially where there is menorrhagia. The liquor 
hydrastis canadensis may be used alternately with ergot, although it is 
not nearly so trustworthy. 

The passive congestion can also be relieved by depletion, although 
this is not used nearly so much now as formerly. The best mode is by 
scarification of the cervix ; but we would limit its use to cases where 
there is marked cervical hypertrophy. A more practical method is the 
abstraction of serum from the tissues by glycerine tampons, which have 
this advantage that they can be applied by a nurse, or even by the 
patient herself. A 10 per cent solution of ichthyol and glycerine I have 
found even more serviceable than simple glycerine. A course of systematic 
douching, combined with ichthyol tampons, in the hands of a trained nurse 
for several weeks is, in my experience, the most satisfactorjdocal treatment 
for chronic metritis. AYhere the parts are too tender for the regular 
application of ichthyol tampons, ichthyol pessaries are a useful substitute. 

Attention to regular evacuation of the bowels is of the greatest con- 
sequence not only for lessening pelvic congestion, but also for improving 
assimilation. The benefit derived from certain mineral waters is prob- 
ably due largely to their aperient action as well as to the regular mode 
of life prescribed at the different health resorts. 

When exacerbations occur, showing that the affection has become 
acute for the time, we have recourse to hip-baths or warm fomentations 
with complete rest, and to morphia suppositories to relieve the pain and 
check the diarrhoea which are sometimes present. For the irritability 



2i8 SYSTEM OF GYNAECOLOGY 

of the bladder the hot vaginal douche and the usual sedatives are 
useful. 

Where cervical catarrh or endometritis are the prominent features, 
these must be treated in the first instance ; and the treatment directed to 
them will lessen the chronic metritis. While separating these various 
affections for the purpose of studying them, we must remember the 
intimate relation that exists between them ; so intimate is it, that some 
writers prefer to consider inflammation of the uterus as one affection 
varying in its manifestations according to the tissue involved. I do not 
accept this view, inasmuch as it suggests that there is an entity — inflam- 
mation — appearing in one tissue after another. Of the close causal con- 
nection, however, between inflammation in one part and another, there 
is no doubt. Chronic metritis is intimately related both to endometritis 
and to cervical catarrh, and can sometimes be treated only through these. 
Thus, after curetting the uterus for endometritis after abortion, or after 
amputating a hypertrophied cervix, we find an enlarged uterus becoming 
smaller, and the general condition of the patient undergoing improvement. 

Attention to the general health is of great importance. The patient's 
diet requires careful study, and we must have regard to digestion as well 
as to appetite. AVhile some patients require feeding up, others call for 
a restriction of food. A patient may eat well and largely, and yet 
assimilation may be defective. When this is the case, alcohol is often 
taken, from the idea that it aids digestion instead of retarding it. 
Marked improvement in the patient's general condition often follows on 
the prescription of a dietary of light and easily digested food, with a 
diminution in the amount of stimulant. Each case must, of course, be 
studied by itself. No rules can be laid down except that we should not 
let the condition of the uterus divert attention from the condition of the 
stomach. 

Change of air, change of scene and occupation, are invaluable. It is 
to their influence as much as to the mineral waters that the benefit from 
visiting the various spas is due. It would be out of place here to 
enumerate them., and the subject has become of such importance that 
special works on the subject must be consulted. 

The operative treatmentof chronic metritis occupies a very subordinate 
place. After operations on the cervix it has been noted that an enlarged 
uterus diminishes in size : this is specially the case after amputation of 
the cervix. Although this is a very important result of the operation, the 
value of which I have noted repeatedly, I should hardly describe it as a 
means of treating chronic metritis, as the operation is only called for 
where the hypertrophy of the cervix itself is so great as to justify 
amputation on independent grounds. Of the diminution of the uterus 
after Emmet's operation I have not been able to satisfy myself, although 
Emmet and other American operators claim this as one of its beneficial 
results. Of the igni-puncture of the cervix advocated by Prochownik, I 
have had no experience. 

A. H. Freeland Barbour. 



INFLAMMATION OF THE UTERUS 219 



REFERENCES 

1. Atthill. " On Endometritis," Duhlin Journal of Medical Science, Jan. 1873. — 
2. Bennet, Henry. Practical Treatise on Inflammation, Ulceration, and Induration 
of the Neck of the Uterus. London, 1845. — 3. Ibid. A Revieiu of the present State of 
Uterine Pathology, p. 11. Loud. 1856. — 4. Brennecke. " Zur Aetiologie der Endo- 
metritis Fungosa," etc., Archiv f. Gyn. Bd. xx. S. 455. — 5. Bumm. " Ueber die 
Aufgaben weiterer Forschungen auf dem Gebiete der puerperalen Wundinfection," 
Archiv f. Gyn. xxxiv. S. 325. — 6. Cornil. Le<;on sur V Anatoniie pathologique des 
Metrites, etc. Paris, 1889. — 7. Czempin. " Ueber die Beziehung der Uterussehleimhaut 
zuderErkrankungender Adnexa," Zeits.f. Geb.u. Gyn. Bd. xiii. Hft.2. — 8. Doderlein. 
" Ueber Vorkommen und Bedeutung der Micro-organismen in der Lochien gesunder und 
kranker Wochueriuuen," Centralb. f. Gyn. 1888, No. 23. — 9. Duncan, Matthews. 
Diseases of Women. London, 1886.— 10. Fischel. " Ein Beitrag zur Histologie der 
Erosienen der Portio Vaginalis Uteri," Archiv f. Gyn. Bd. xv. S. 76. — 11. Fritsch. 
Die Lageverdnderungen und die Entzdndungen der Gebiinnutter. Stuttgart, 1885. — 12. 
GoNNER. Ueber Micro-organismen im Secret der ivieblichen Genitalien icdhrend der 
Schw anger schaft und bei puerperalen Erkrankungen, 1887, S. 444. — 13. Gooch. On 
some of the most important Diseases peculiar to Women, etc., pp. 156, 157. New Syden- 
ham Society. Loud. 1859. — 14. Gottschalk. Centralb. f. Gyn. 18r;5. No. 27. — 15. 
Hart, D. Berry. " Tlie Pathological Classification of Diseases of Women, with a 
Plea for a Revision of Current Yiev.s," Edin. Obstet. Trans, vol. xix. p. 82. — 16. 
Heinricius. "Ueber die chronische hyperplasirende Endometritis," ^rc/iiu /. Gyn. 
Bd. xxviii. S. 163. — 17. Hofmeier. " Folgezustaude des chrouiscben Cervixkatarrhs 
und ihre Behandlung," Zeitsch. f. Geb. u. Gyn. Bd. iv. S. 331. — 18. Immerwahr. 
Centralblatt f. Gyn. 1895, No. 26. — 19. Klotz. Gyniikologische Studien liber die patho- 
logischen Verdnderungen der Portio Vaginalis Uteri. Wien, 1879. — 20. Kuestner. 
Beitrdge zur Lehre von der Endometritis. Jena, 1883. — 21. Lee. Trans, of the Med.- 
Chir. Soc. vol. xxxiii. p. 270. — 22. Menge. Centralb. f. Gyn. 1895, S. 714.-23. 
Olshausen. "Ueber chronische hyperplasirende Endometritis des Corpus Uteri," 
Archiv f. Gyndk. Bd. viii. Hft. 1. — 24. Palmer. The Inflammatory Affections of the 
Uterus : a System of Gynsecology, by American Authors. Edited by Matthew D. Mann. 
Edin. 1887. — 25. Pfannenstiel. " Kasuistische Beitrage zur Aetiologie des Puer- 
peralfiebers," Centralb. f. Gyn. 1888, S. 617. — 26. Playfair, W. S. " Intra-uterine 
Medication," British Medical JoiLrnal, Dec. 1869, March, 1880; Lance?, Jan. and Feb. 
1873. — 27. Pozzi. Treatise on Gynse2ology, Clinical and Operative, The New Sj^den- 
ham Society Translation, 1892. — 28. Priestley, Sir W. O. Inflammation of the Uterus, 
A System of Medicine, edited by J. Russell Reynolds, M.D. vol. v. London, 1879. — 
29. RuGE. " Zur Aetiologie und Anatomic der Endometritis," Zeits.f. Geb. u. Gyn. Bd. 
v. S. 317. — 30. RuGE and Veit. "Zur Pathologic der Yaginalportion," Zeits.f. Geb. 
u. Gyn. 1878, Bd. ii. S. 415. — 31. Scanzoni. Die chronische Metritis. Wien, 1863. 
— 32. Schroeder. Charite annalen v. Berlin, 1880, S. 340. —33. Simpson, Sir James. 
Diseases of Woinen, p. 585. Edin. 1872. — 34. Sinclair, Wm. Japp. On Gonorrhuial 
Infection in Women. Lond. 1888. — 35. Sinety, De. Manuel de Gynecologic, p. 327. 
Paris, 1879. — 36. Ibid. Pp. 315, 351. — 37. Smith, Tyler. "Observations on the 
supposed Frequency of Ulceration of the Os and Cervix Uteri," Lancet, vol. i. 1850, p. 
474.-38. Spiegelberg. " Die Diagnose des ersten Stadium des Carcinoma Colli Uteri," 
Archiv f. Gyn. iii. S. 233.-39. Thomas. Diseases of Women. Edited by Paul F. 
Munde. London, 1891. —40. West. On the Pathological Importance of Ulceration of 
the Os Uteri, Croonmn'LecXxvcQS. London, 1854. — 41. Ibid. Diseases of Women. London, 
1856. — 42. Winckel. " Bericht iiber die Verhandlungen der sechsten Versammlung 
der deutschen Gesellschaft fiir Gynakologie," Centralb. f. Gyn. 1895. No. 26.-43. 
Winter. " Die Micro-organismen im Genitalcanal der gesunden Fran," Zeitsch. f. Geb. 
u. Gyn. Bd. xiv. Hft. 2, S. 443.-44. Wyder. Tafeln fur den gyndk. Unterricht. 
Berlin, 1887. — 45. Ibid. " Die Mucosa Uteri, bei Myomen," Archiv f. Gyn. xxix. p. 1. 



A. H. F. B. 



SYSTEM OF GYNECOLOGY 



THE NERVOUS SYSTEM IN RELATION TO GYNECOLOGY 

In tlie study of gynsecology a cardinal factor, which is often under- 
estimated and even altogether overlooked, is the highly sensitive nerv- 
ous organisation of the female sex. The mobility of the nervous 
system, especially in the sphere of the emotions, which distinguishes 
the woman from the man, influences the character and progress of all 
kinds of disease in women, but more especially diseases of the repro- 
ductive organs. This factor calls for very careful consideration. 

Up to the time of puberty there is little if any marked difference 
between the sexes, either in health, in disease, or in any other condition. 
Conventionally they are separated ; but boys and girls will play together, 
work together, and associate generally in perfect equality ; the qualities 
which distinguish one sex from the other being either latent or seen but 
obscurely. As soon, however, as the great function of menstruation is 
established, which is henceforth to influence the woman during the whole 
period of her sexual life, the entire system undergoes a marked change : 
the asexual child becomes a woman ; her body undergoes characteristic 
modifications fully described in all works on physiology and obstetrics ; 
and with them are to be observed the not less important changes in 
character, and in the general development of the nervous system, which 
distinguish the woman from the girl. It is at this important time that 
the conduct of the health of the growing girl may influence for good 
or for evil the whole future of the woman. Judiciously managed, she 
may be so trained that she will be able to meet successfully the strain 
on her nervous system during her future life ; the duties of a wife 
and mother, the struggle with domestic anxieties and worries, or the 
sorrows which are rarely altogether absent from the lot of mankind. 
Injudiciously managed, as is the case with so many at this important 
epoch, all those things, which the strong-bodied and healthily minded 
woman may bear with no permanent bad results, will tell terribly upon 
her. She will have no stamina, no power of resistance ; and she may 
become the wretched, broken-down invalid so often met with in the 
present day, especially in those ranks of life in which the evil effects 
of unbalanced culture, and the bringing up of girls like hothouse plants, 
are so frequently seen. 

This being so, it may be well to preface what has to be said on the 
influence of the nervous system on gynaecology by a few words on 
the education and training of girls at and after the establishment of 
puberty. This is all the more necessary since the higher education of 
women has taken such enormous strides of late years that it is now 
regularly recognised, and is almost uuiversal. The " High Schools " for 
girls are to be met with everywhere, and the still more advanced colleges 



THE NERVOUS SYSTEM IN RELATION TO GYNECOLOGY 221 

of the type of Girton and Newnham are rapidly increasing in number, 
and are full of students. The old-fashioned girls' boarding-schools, 
with their perfunctory education and their elegant accomplishments, 
are driven out of the held ; and a movement which at first was scoffed 
and jeered at has now gained the day. 

Let me say at once that, with limitations which are essential because 
of the difference of sex which cannot be got over, the movement is one 
which seems to me an enormous gain, and of it I write in no spirit of 
opposition. This statement is needful, since there is an unfortunate 
tendency on the part of many mistresses of high schools to listen to the 
warnings of medical men with incredulity, and to accuse them of narrow- 
mindedness and opposition, of which, as a matter of fact, the great 
majority of them are in no way guilty. The recognition of possible 
evils, and due warning against them, are neither the one nor the other. 

The one great fault of those who manage these educational establish- 
ments is that they have too often started on the absolutely untenable 
theory that the sexual factor is of secondary importance ; and that 
there is little if any real distinction between a girl between the ages of 
14 and 20, and a boy of the same age. 

I know of no large school for girls where the absolute distinction 
which exists between boys and girls as regards the dominant menstrual 
function is systematically cared for and attended to. The feeling 
of all school mistresses seems to be antagonistic to such an admission. 
The contention is that there is no real difference between an adolescent 
man and woman; that what is good for one is good for the other; that 
the apparent differences are due to the evil customs of the past, which 
have denied to women the ambitions and advantages open to men, and 
that these will disappear when a happier era is inaugurated. If this be 
so, how comes it that while every physician of experience sees many 
cases of anaemia and chlorosis in girls, accompanied by amenorrhoea or 
menorrhagia, headaches, palpitations, emaciation, and all the familiar 
accompaniments of break-down, an analogous condition in a school-boy 
is so rare that we may well doubt if it is ever seen at all ? 

These disorders certainly do not necessarily result from the work. 
The successes of women in the schools have been so striking and numer- 
ous that their capacity for intellectual work cannot be doubted for a 
moment. On the other hand, the male's work is safeguarded by an 
amount of physical exertion in the way of sport which serves to keep him 
in health. It is true that in university colleges and in a few girls' 
schools attention has been paid to this point of late ; but in a perfunctory 
sort of way at the best. There may be a gymnasium, or some form of 
games ; but while at a boys' school cricket and football are compulsory 
— to say nothing of the natural disposition of a boy to athletic pursuits — 
at a girls' school, exercise is optional ; and if a pupil tending to ill-health 
avoids it, little or no attention is paid to the matter. Within the past 
week as I write, I have been consulted in the cases of two young ladies, 
aged respectively 14 and 16. One was chlorotic, and her menstruation 



SYSTEM OF GYNECOLOGY 



liad ceased for a year. On taking lier time-table at a well-known high 
school, she had 7-| hours' work, — an amount not in itself, perhaps, exces- 
sive in a healthy girl. From 2.30 to 4 there were no lessons, and, if the 
weather permitted, she might if she liked take a walk ; but it was not 
insisted upon ; and as she was naturally languid and listless, as all such 
girls are, she rarely did so. There was no other opportunity for exercise 
at all. The other girl suffered from pronounced menorrhagia, anaemia, 
and debility. Her time-table was also seven to eight hours, and she 
" occasionally took a walk." In neither of these cases had the school 
authorities ever inquired into the state of an all-important bodily 
function, which in both was very markedly aberrant ; yet, considering 
the paramount importance of such symptoms of impaired health in girls 
of these ages, it might fairly be held to be part of the duty of those in 
authority in such schools to make the necessary inquiries, and to mod- 
ify the course of study or mode of life accordingly. 

While it is questionable whether in boys' schools the attention given 
to exercise and athletics may not be excessive, in girls' schools it is, on 
the other hand, not nearly sufficient. And yet this is a fault which 
might be very easily remedied. It would not be difficult to make the 
games of girls' schools compulsory as they are in public schools for boys ; 
there are many games admirably adapted for women, as, for example, 
golf, hockey, lawn tennis, rowing where it is feasible, or, it may be, 
bicycling. Each of these exercises the muscles generally without the 
spasmodic efforts required in cricket or football, which may be too 
violent for some girls. The result when such games are freely used 
must be well known to all who have a knowledge of what a thoroughly 
healthy English girl may be. No better description of it could be given 
than that contained in a leading article in the Speaker, on what the 
writer calls " The Lawn Tennis Girl " : — 

Sensible people have long ago agreed to accept this new type of womanhood as 
being distinctly admirable. She has made her influence felt everywhere, both in 
real life and in fiction. In real life we meet lier in every country house, in every 
foreign hotel, and almost in every London square. And wherever we meet her 
we come upon an excellent example of the healthy, well-developed, and unsenti- 
mental girl — the girl who does not think it necessary to devote herself to the 
study of her own emotions, and who finds in active physical exercise an antidote 
to the morbid fancies which are too apt to creep into the mind of the idle and 
self-indulgent (13). 

This is an excellent description of a type with which we are all 
familiar, and, it is needless to say, we all admire. If high-class schools 
could succeed in turning out girls of this kind in larger numbers than 
at present, they would do more towards lessening the number of neu- 
rotic women the medical profession has to deal with than the medical 
profession can possibly do by any exercise of its own art. 

It is an obvious corollary from what has been said, that it is the 
bounden duty of mistress, parent, and doctor to insist at once on the 



THE NERVOUS SYSTEM IN RELATION TO GYNAECOLOGY 223 

cessation of all severe study when any of the physical signs of illness, such 
as it is impossible to mistake, have shown themselves, — as, for example, 
chlorosis, amenorrhoea or menorrhagia, wasting, loss of appetite, and the 
like. In my judgment it is not work which hurts, but perseverance in 
work after nature has hung out its danger-signals — work in an unhealthy 
body, the attempt, in fact, to fight nature. Then, indeed, the careless, 
prejudiced, and unwise mistress or parent may well find out that the 
results of '^ over-pressure," the very existence of which so many deny, are 
a stern reality, and may shatter the whole future of the girl. 

In the present article we are not called upon so much to consider 
the subject of the nervous system in general, as its special influence on 
our work as gynaecologists. Still, the important question naturally 
suggests itself. Are morbid nervous states, of the type now generally 
known as neurasthenic, on the increase amongst us ? Or is their sup- 
posed prevalence due to more careful observation, and the recognition 
of conditions formerly unobserved, and not referred to their proper 
source ? 

To these questions it is not easy to give a satisfactory reply, for no 
defiuite statistics exist by which they can be settled. It is pretty certain 
that morbid functional neuroses are far more common in the cultured 
and educated classes than in the comparatively uneducated. This 
accounts for the absence of cases of advanced neurasthenia in our hospital 
wards and out-patient clinics in England. Such states are indeed almost 
limited to private practice among the upper classes of society; and they 
may explain, to a great extent, the comparative neglect of such illnesses, 
all-important though they be, by our clinical teachers, whose material for 
instruction is chiefly, if not altogether, supplied by hospital patients. 
There can be no doubt that culture and education, and their results 
in increased nerve stimulation, have taken enormous strides within the 
last fifty years. This has been well illustrated by Max jS'ordau in his 
remarkable work on Degeneration. " In 1840,'' he says, " there were in 
Europe 3000 kilometres of railway ; in 1891 there were 218,000 kilo- 
metres. The number of travellers in 1840 in Germany, France, and 
England amounted to 21 millions; in 1891 it was 614 millions. In 
Germany every inhabitant received in 1840, 8 letters ; in 1888, 200 
letters. In 1840 the post distributed in France 94 millions of letters, 
in England 277 millions ; in 1881, 595 and 1299 millions respectively. 
In Germany in 1840, 305 newspapers were published ; in 1891, 6800 : 
in France 750 and 5782; and in England (1846) 551 and 2255. Ali 
activities, even the simplest, involve an effort of the nervous system 
and a wearing of tissue. In the last fifty years the population of Europe 
has not doubled, whereas the sum of its labours has increased tenfold. 
in parts even fiftyf old. Every civilised man furnishes at the present time 
from five to twenty-five times as much work as was demanded of him 
half a century ago." 

It is reasonable to conclude that nervous breakdown and morbid 
states of the nervous system of all kinds should increase pari passu with 



224 SYSTEM OF GYJV.^COLOGY 

the increasing developments of nerve work referred to, and sucli is proba- 
bly the case. 

It is indeed likely that many illnesses, formerly misunderstood and 
neglected as being beyond the power of the practitioner to alleviate, are 
now referred to their proper cause, and correctly diagnosed. 

This is the view taken by Professor Allbutt, who contends that 
neurasthenia is not more frequent than it has been for some generations 
past, but that it is better understood. Every one will concede the cor- 
rectness of his contention that the more a nervous system is worked the 
better it is for its owner, with this reservation, which he fails to insist 
on, that this must be in a healthy body. As has already been pointed out, 
it is not work that seems to hurt, but work plus something else, such as 
physical frailty, worry, anxiety, and the like ; and these persisted in in 
spite of warning. It will probably be generally admitted that the condi- 
tions of modern society are such as to make this kind of addition to work 
of the nervous system increasingly common. It is remarkable, moreover, 
that this type of disease is far more frequently met with in what may be 
called the centres of nervous energy and strain. I have constantly ob- 
served that such cases are enormously more frequent in such centres of 
active work as G-lasgow, Liverpool, Leeds, and Manchester, than in the 
comparatively idle and fashionable members of West End London society. 
This is borne out by the returns of the Registrar-General, which show 
that in the census year the death-rate from nervous diseases in London 
was only about 22 per 10,000 persons living, while it runs up to 2S-6 for 
Lancashire, 29-5 for the West Eiding, 31*8 in Leeds, 32-8 in Blackburn, 
33-7 in Preston, and 34-5 in Sheffield. 

The reason of this is probably complex. Partly it may be due to 
heredity, since patients from such places are generally the daughters of 
busy, active, pushing business men, who have been the architects of their 
own fortunes ; partly it may be due to the fact that such patients live in 
an atmosphere of strain and bustle, and in which vicissitudes of fortune 
are far from uncommon. 

Similarly these types of diseases are said to be much more frequent 
in such new and very "go ahead" countries as Australia and America; so 
much so, that neurasthenia has been by some described as the "American 
disease." It is often said that national peculiarities have a great deal to 
do with determining the liability to these illnesses. Thus it is remarkable 
how comparatively rare in this country are the aggravated types of hystero- 
neurosis (such as are apparently common enough in France, if we may 
judge by the writings of Charcot), accompanied by trance, contractures, 
and the like ; and this may justly be attributed to the greater general 
excitability of French women. This disease is, however, very unlike 
general neurasthenia, which is certainly something altogether different 
from the so-called hysterical state, andis by no means necessarily — or even 
most frequently in my experience — met with in women of very excitable 
temperament ; or at any rate not in idle and fanciful women ; it is seen 
rather in women of more than average intellect, who have exhausted 



THE NERVOUS SYSTEM TV RELATION TO GYNECOLOGY 225 

their nervous systems by undue strain or anxiety, and who have struggled 
with the early symptoms of '^nerve-tire," and refused to take note of the 
signs of impending mischief. 

Having said so much as to prevention, which is so much better than 
cure, as regards the healthy action of the nervous system in women, let 
us now proceed to consider it in its morbid action as we observe it in the 
study of gynaecology. 

Functional neuroses arise easily in women; they may assume 
tremendous proportions, and their growth may be readily fostered and 
encouraged until, like some noxious weed, they choke all health of body 
and mind. But it is not easy, when once they are fully established, to 
trace them to their source ; and unless we get at all the "fontes et origines 
mcdi,^^ which may differ much in different cases, any rational system of 
cure is practically impossible. 

Broadly speaking, Ave may say that there are two classes of cases 
with which Ave have chiefly to deal : 

1. We may have some definite uterine or peh^ic lesion, which may be 
the starting-point of secondary reflex neurotic complications, and in these 
cases attention is mainly to be directed to the cure of the originating 
local complaint. 

2. We may have a condition in which some local lesion, in itself of 
minor importance, may be found, or has been found. This, indeed, may 
even be only a secondary result of the general neurotic condition which is 
the dominant factor in the patient's health ; and the treatment of it may 
not only be inadmissible but, injudiciously carried out, may be intensely 
prejudicial, and very gravely increase the general ill health from A\diich 
the patient suffers. As a further development of this, Ave may often meet 
with cases in Avhich some definite existing local lesion very probably 
started the illness, but which has in time become so over-shadowed by its 
OAvn secondary consequences that the judicious practitioner will minimise 
any treatment of it as much as possible. 

The importance of the first class of case is certainly very great, and 
deserves the most careful study on the part of the gynaecologist. 

There can be little doubt that secondary functional disturbance of 
remote organs very commonly originates in some definite morbid 
local condition of the uterus or ovaries, the irritation being conducted 
along the ganglionic and spinal nervous system. Every practitioner is 
familiar Avith the influence of the reproductive system in producing such 
a disturbance of distant organs as the neuroses of pregnancy ; not only 
the commonly observed morning sickness, Avhich may run into uncontrol- 
lable and even fatal A^omiting, but other neuroses of an obviously similar 
type, but less commonly recognised, as, for example, excessive saliA'ation, 
cardiac disturbances, the so-called " lypothymia," or partial trance, and 
such AA^ell-marked mental conditions as extreme depression of spirits or 
insanity. 

It is familiar to the obstetrician that in many of these cases all general 
treatment fails, while local treatment^ such as the application of carbolic 

Q 



226 SYSTEM OF GYNECOLOGY 

acid or iodine to an inflamed or abraded cervix, or the lifting of a 
retroverted gravid uterus out of the pelvic cavity, may give relief at 
once. 

That similar local irritations in the non-pregnant woman may set up 
marked distal disturbances is a fact which the general physician is very 
apt to overlook ; hence many a sufferer has been uselessly treated by 
incessant drugging, whose symptoms would at once have disappeared if 
the coexisting uterine or ovarian source of irritation had been detected 
and relieved. 

Of course it is imperative that care should be taken not to overlook 
any unsuspected source of illness of this kind. Should some obvious 
lesion be found — such, for example, as a hyperplastic uterus, a badly 
lacerated and everted cervix, profuse uterine or cervical catarrh, swollen 
and tender ovaries and tubes, well-marked flexion or version — then no 
judicious practitioner would fail to remedy it by appropriate treatment, 
the details of which are fully considered in the several articles of this 
work. Above all things, however, it is essential that there should be 
no mistake about this — that the lesion we are treating should be real, de- 
cided, and unmistakable, and that the local treatment should be judicious 
and minimised as much as possible. We shall presently have to dwell 
more particularly on the evil effects which in nervous and emotional 
women are apt to follow injudicious and over-frequently repeated local 
treatment. 

There are two possible errors which may be made in connection with 
this matter. One is that a distinct local lesion, which is the originating 
cause of a secondary nervous disturbance, may be overlooked and not 
treated at all ; and thus the nervous condition may be maintained. The 
other is that exaggerated importance may be attached to some local 
lesion which is detected ; that the error of diagnosis may be accompanied 
by an error of judgment, and that much needless local treatment of 
what maybe called the " tinkering" kind is adopted: thus the coexisting 
neurosis is aggravated. Both mistakes are serious ones ; but I am con- 
strained to say — and the more I see of neurotic women the more convinced 
I am — that the latter is much the more serious and common of the two. 
Nothing can be more deplorably bad for a nervous, emotional woman, 
whose general health is at a low ebb, than to have her attention con- 
stantly directed to her reproductive organs by vaginal examinations 
repeated two or three times a week, pessaries constantly introduced for 
" a slight displacement," the cervix frequently cauterised, or the endo- 
metrium curetted, and the like ; and yet these are things one incessantly 
sees in cases in which, on examination, no definite reason for such inter- 
ference is found to exist. No doubt it is generally done in good faith ; 
but the results are often disastrous, and I feel it to be my duty to insist 
very emphatically on the necessity of carefulness in this direction. 

These remarks apply more especially to the second class of case 
referred to, in which we are justified in concluding that the local affection 
was either of secondary importance from the beginning, or has become so 



THE NERVOUS SYSTEM IX RELATION TO GYNECOLOGY 227 

in consequence of long-existing bad bodily health, and the supervention 
of a morbid neurotic condition. 

It is scarcely consistent with the limits of this paper, which specially 
contemplates the discussion of such neurotic complications as come under 
OLir observations as gynaecologists, to enter into a detailed description 
of the conditions known of late years as " Neurasthenic " 5 these will 
naturally be more fully discussed under this head. Indeed they are 
protean in character, and in no two cases are the symptoms identical. 
This one might expect, as the main element in the morbid state we have 
to deal with is the unhealthy action of a subtle and invisible function, 
quite beyond those ready means of examination which we can apply to 
the heart, lungs, or digestive organs, but which influences any or all of 
them nevertheless. Hence the risk of mistaking disturbed action of 
various parts and viscera — as, for example, insomnia, headache, spine- 
ache, palpitations, nausea, loss of appetite, and a host of other condi- 
tions — for diseased states of parts which, in themselves, may well be 
substantially healthy. Exactly the same error may be, and often is 
made with reference to apparent disorders of the reproductive system ; 
in these we may find cessation or disorder of menstruation, some increase 
of discharges or secretions, uterine and ovarian pains and aches of vari- 
ous kinds ; but yet no structural lesion of any real moment. 

One permanent characteristic, however, is to be found in all cases 
of this sort which merits the most careful attention, and is constantly 
overlooked ; this is defective general nutrition, involving as this, of 
course, does, badly nourished and therefore imperfectly acting nerve 
centres, and, as a consequence, defective action of all the viscera sup- 
plied and controlled by them. 

This defect is, indeed, the keynote to the treatment of a large number 
of cases of ill health in women, which are often associated with morbid 
conditions referable to the reproductive organs, but are quite incurable 
until the general nutrition and health of the patient is placed on a sat- 
isfactory basis. A woman has some headache, or other disturbance, and 
for this she is perhaps advised to rest. Gradually all healthy habits of 
body are dropped, one by one, until she hardly leaves her sofa, and takes 
no kind of exercise. As a consequence the appetite fails, less and less 
food is taken, and progressive emaciation and great general debility su- 
])ervene, with all the well-known attendant symptoms of chronic inva- 
lidism. Or it may be that another type of defective nutrition shows 
itself, attended with a deposit of unwholesome flabby fat in the subcu- 
taneous tissues ; and the patient, while weak, a poor eater, invalided and 
sofa-ridden, becomes overburdened with unwholesome and useless fat. 

These are precisely the conditions in which emotional disturbances 
of the worst kind appear. Some injudicious relative or friend is rarely 
lacking in such a case who adds fuel to the fire by constant unwise 
nursing and unduly sympathetic attendance. In many instances, it is 
to be feared, the medical man, at his wits' end to do something, makes 
matters worse by constant visiting; endless talks as to symptoms : and 



228 SYSTEM OF GYNAECOLOGY 

incessant prescriptions in whicli the inevitable bromide, and similar 
harmful drugs, play a prominent part. It is a happy thing for his 
patient if amongst them narcotics have not found a place ; too often 
chloral, sulphonal, morphia, and the like have been resorted to, until 
at last the patient may have insensibly sunk into the deplorable habits 
of a chloral or morphia taker. 

This description, of course, refers to the case of the confirmed 
neurasthenic invalid so often to be seen. But short of so advanced a 
type of neurotic illness the gynaecologist cannot fail to call to mind 
numberless women on the down grade, who were drifting into some 
such state of chronic ill health, the physical path to which is defec- 
tive nutrition, and who could almost certainly have been arrested in 
their downward course if the real cause of their illness had been thor- 
oughly appreciated and acted upon. 

It follows from what has been said that, in the large majority of 
neurotic cases coming under our observation in gynaecologic practice, 
the main object of treatment should be to improve the general nutrition, 
and so to aim at better general health. How is this difficult task to be 
accomplished ? It is far easier to point out how it is not to be done ; and, 
unluckily, the path which certainly does not lead to success is the one 
most generally followed. It is certainly useless in a confirmed case of 
this kind to attempt to cure the patient by way of the chemist's shop. 
Gallons of physic have generally been swalloAved by her already, and 
the judicious practitioner will not add to the number of useless or pos- 
sibly harmful prescriptions which a patient of this kind invariably has 
to show. If the case be a comparatively mild one, a little common sense, 
a quality not too generally found in the regulation of the treatment of 
neurotics, may be all that is required. An endeavour to ascertain and 
remove any more immediate causes, if such exist, whether physical or 
mental ; the insistence on a proper amount and quality of easily assimi- 
lated food; the removal from unwholesome domestic surroundings, which 
may be brought about by change of air and scene, — these, or similar pre- 
scriptions, which vary in accordance with the peculiarities of each indi- 
vidual case, may suffice to restore the patient to health, and give back 
to her the efficient control of her nervous system which she had lost. 

In the more severe cases, in which the symptoms of neurasthenia are 
well marked and of long standing, something more definite is required 
to give the patient a fair chance of recovery. Here that combined at- 
tack on defective nutrition known of late years as the *' rest cure," or 
" The Weir Mitchell " treatment (so called after the well-known Ameri- 
can physician to whom we owe its introduction as a systematic method 
of treatment) may, in properly selected cases, prove an invaluable re- 
source. Suffice it to say that, properly and judiciously carried out in 
well-selected cases, its results are most striking and satisfactory, and 
hundreds of women are now going about well and strong who but for 
this would still be the wretched invalids they formerly were. 

As the present writer was mainly instrumental in introducing this 



THE NERVOUS SYSTEM IN RELATION TO GYNECOLOGY 229 

method of treatment into Europe, lie may perhaps be regarded as unduly 
prejudiced in its favour. He ventures, therefore, to quote the estimate 
formed of it by the late lamented American gynsecologist, Dr. Goodell, 
which was probably one of the very last things he ever wrote : — 

One of the grandest discoveries in the treatment of the nervous phase of 
women's diseases is the rest cure, for which we owe a large debt of gratitude to 
Weir Mitchell. Formerly there were in every city, town, and hamlet, sofa- 
ridden and bed-ridden women who were doomed to helpless invalidism under 
the label of "weak spine," of "spinal irritation," of "irritable womb," or of 
" chronic ovaritis." So countless were these cases, in the young and in the old, 
in the married and in the single, in the fruitful and in the barren, so much 
misery was entailed on the sufferer and on her kin, so many homes were 
blighted, so powerless was the medical profession to give help, tliat the pathetic 
lament of the Hebrew prophet could not have been better applied than to this 
great and wide-spreading scourge, "Is there no balm in Gilead ? Is there no 
physician there ? Why then is not the health of the daughter of my people 
recovered ?" Yet now I think myself safe in the assertion that very few of these 
cases are incurable, and that no other discovery in medicine has raised so many 
women from their beds and restored them to lives of active usefulness. It is the 
miracle of modern therapeutics. 

It is, however, essential that if treatment of this kind is to prove 
useful it should be adopted in properly chosen cases only, and that when 
it is attempted it should be done thoroughly and well. Constant failures 
arise from neglect of one or other of these points, especially of the latter. 
There is much that is disagreeable about this treatment, at least in 
appearance ; especially the removal of the patient from her usual domestic 
surroundings, and her seclusion in a properly managed medical home. 
This is naturally disliked, and it leads to much expense. Pressure is, 
therefore, put on the medical man, to which he is often weak enough to 
yield, to treat the case in what is called " a modified way," by " trying a 
little massage" (this being one of the remedial agents) at the patient's 
own home, or in some other way to try to play " Hamlet " with the 
part of Hamlet left out. The inevitable consequence is failure and dis- 
appointment, a really good and valuable method of treatment is dis- 
credited, and the patient's state is made worse rather than better. I 
have seen so much of this that I cannot too urgently insist on the 
necessity of thoroughness in any attempt to carry out this means of 
cure. 

An interesting question in relation to diseases of the nervous system 
in gynaecology arises in connection with insanity. Some have held 
that insanity may actually depend on morbid conditions of the repro- 
ductive organs; and it has even been suggested that for the cure of 
certain forms of insanity associated with pronounced sexual aberrations — 
such as excessive masturbation and erotic manifestations — the uterine 
appendages should be removed by operation. Of this alleged connec- 
tion I have never been able to find any reliable evidence at all. Of 
course insane women are liable to uterine disease as sane women are ; 



230 SYSTEM OF GYNECOLOGY 

and when they have marked disease of the reproductive organs, of what- 
ever type, it should be appropriately treated, whatever the condition of 
the mental functions. Inasmuch as the medical staff of asylums are 
rarely expert in gynaecology, it is likely that where so many women are 
congregated together there may be found a considerable amount of 
undetected pelvic disease which should be made the subject of treat- 
ment. 

In a paper on this subject Brown contends that fully 2h per 
cent of the female patients in asylums in the United States suffer from 
some form of pelvic disease. If this be true, it follows that alienist 
physicians should not neglect the study of gynaecology more than any 
other department of medicine. But while this may be admitted it does 
not follow that the one has any direct connection with the other. Un- 
happily it has been very common to revert in a haphazard way to 
operative interference, which, in my opinion, is unscientific, unnecessary, 
and often hurtful. The excessive masturbation and various erotic 
manifestations so common in certain types of insanity are, it cannot be 
reasonably doubted, phenomena of central, and not of peripheral origin; to 
remove the ovaries or tubes by way of curing them seems to be altogether 
unreasonable. It may be laid down as an axiom, which is consistent with 
the most generally received opinion of the profession, that no operation 
of this kind is permissible in an insane patient unless some structural 
lesion exist which would call for or justify the operation were the patient 
sane. Of the uselessness of such a procedure a marked example is given 
in Case IV. of Brown's paper above referred to. 

There are other forms of neurotic disease, however, in which this 
operation has also been recommended and performed, in which, in my 
opinion, it is still less admissible. Of late years, unhappily, it has been 
a not uncommon practice to remove the uterine appendages in various 
intractable forms of functional neurosis, not because they showed any 
kind of structural disease, but because the neurotic condition had pre- 
viously resisted all ordinary means of treatment. In a paper on this 
subject, published in the thirty-third volume of the Obstetrical Transac- 
tions, I have fully discussed this procedure, and have brought forward 
evidence to show its utter uselessness. It is impossible to speak too 
emphatically in condemnation of a rash and irretrievable experiment of 
this kind. 

The only class of case in which such operations have any reasonable 
claim for consideration are those of hystero-epilepsy, or other very severe 
forms of nervous disease, which are regularly aggravated at the men- 
strual periods, and may therefore be assumed to be in some way connected 
with that function. It does not follow that because such cases are worse 
during menstruation, when all the bodily functions are naturally in a 
state of unstable equilibrium, that they depend upon it. Still the 
supposition that the artificial production of the menopause should have 
a curative effect in such cases is a sufficiently reasonable hypothesis, and 
it is not surprising that the operation should have been often performed 



STERILITY 231 

in such cases. The records, however, are not satisfactory. Of the cases 
of this kind which have been published of late years, something like 50 
l)er cent were complete failures ; and even in a well-marked case the 
outcome of experience tends to show that operative interference should 
not be resorted to unless distinct evidence of coincident structural mis- 
chief exist. 

W. S. Playfair, 

REFERENCES 

1. Allbutt, Prof. Clifford, " The Nervous Diseases of Modern Life," Contemporain/ 
Revieio, Feb. 1895. — 2. Baker, Fordyce. " Uterine Diseases as a Cause of Insanity," 
Journal of the Gynxcological Society of Boston, Jan. 1873. — 3. Boldt, H. I. " Cardiac 
Neurosis in connection with Ovarian and Uterine Disease," American Journal of Ob- 
stetrics, vol. xix. — 4. Brow>^, John Young. "Pelvic Disease in its Relationship to 
Insanity in Women," American Journal of Obstetrics, vol. xxx. — 5. Goodell, Wm. 
" The abuse of Uterine Treatment through mistaken Diagnosis," The Medical Neios, 
Dec. 7, 1889; Clinical Gyngecology by Amei^ican Authors, vol. i. — 6. IMuret. " Le 
roledusystemenerveux dans les affections gynecologiques," Revue me'cUcale cle la Suisse, 
June 1884. — 7. Nordau, Max. Degeneration (English translation), William Heine- 
mann, 1895. — 8. Ohr, C. H. " Genital Reflex Neurosis in Females," American Journal 
of Obstetrics, vol. xvi. — 9. Playfair, W. S. "On the removal of the Uterine Ap- 
pendages in cases of Functional Neuroses," Obstetrical Transactions, vol. xxxiii. — 10. 
8emon, Felix. "The Sensory Throat Neurosis of the Climacteric 'Pev\od," British 
Medical Journal, Jan. 5, 1895. — 11. Skene. "Gynaecology as related to Insanity in 
Women," Diseases of Women, p. 929 et seq. — 12. Store. The Course and Treatment of 
Reflex Insanity in Women. — 13. "The New Woman and the Old," The Speaker, Jan. 
12, 1895. 

w. s. p. 



STEEILITY 



Sterility implies that condition in a woman in consequence of which 
she either does not conceive, or if she conceive is unable to bear a 
living and viable child. 

Sterility depending on generative defects in the male will not be 
considered here, although unquestionably a certain percentage of cases 
of sterility in the woman (variously estimated by writers on the subject 
as from 7 to 15 per cent) depends upon some such defect in the 
husband. The cognate subject of the sterility of a woman with one 
husband but not with another, when in neither there appears to be 
any physical defect, will be considered under the heading of relative 
sterility. To apply the name sterility to the incapacity to conceive 
which exists before puberty and after the menopause appears scarcely 
appropriate. Sterility under these circumstances is strictly physiological ; 
it is not governed by the commencement or decline of menstruation, 
except in so far as these epochs coincide with the commencement and 
cessation of ovulation. Provided ovulation continue, fertility may pre- 



232 SYSTEM OF GYNECOLOGY 

cede menstruation, exist during intervals of its suppression, and beyond 
the menopause. But, although the capacity to conceive may continue 
until menstruation ceases and even for some time afterwards, in the 
majority of women child-bearing terminates some six or seven years 
prior to that occurrence. The small minority in whom conception occurs 
not only up to the usual time of the menopause, but also beyond it, is 
largely constituted of healthy women who have married late in life, and 
in whom there may, consequently, be an unexpended reserve of fertility. 

The statistics given by writers of the proportion of sterile to prolihc 
marriages vary much ; and this is scarcely surprising considering the 
w^ide range of conditions under which marriages take place. Such con- 
ditions include the age at marriage, individual health, social habits, and 
the customs peculiar to countries or districts. But probably the con- 
clusion of Matthews Duncan, whose works on this subject are classical, 
is fairly near the mark when he estimates that in Great Britain the pro- 
portion of one in ten represents the number of sterile marriages ; that 
the most usual time after marriage for the first birth to occur is from 
twelve to fifteen months, but that three years may be allowed to elapse 
before any strong presumption of sterility need be entertained : lastly, 
he considers the most fertile period of a woman's life to extend over 
twelve years, from about twenty-six to about thirty-eight. 

Classification of the Conditions leading to Sterility. — The most 
usual classification is into absolute and relative ; another is into con- 
genital and acquired; another into permanent and temporary. Dr. 
M. Duncan's division is threefold. His first class he terms the class of 
absolute sterility ; in it he includes all cases " in which there is no child, 
no miscarriage, no abortion, however early " ; this class, he adds, is some- 
times called congenital. His second class he defines as including cases 
of " sterility not absolute " ; by which he implies the failure to produce 
a viable child while there may be evidence of conception. His third class 
he calls relative or acquired sterility, and in it he includes cases " where a 
woman produces one or even several living children, but in number not 
according to her conditions of age and length of married life." The term 
relative sterility, however, is more frequently used to indicate the sterility 
which a woman manifests with one husband, but not Avith another, and 
in which, therefore, the fault may be on the husband's side ; or, on the 
other hand, she may have been suffering from some defect of the gen- 
erative system during the time of her earlier marriage which ceases to 
be potent before her second. The term relative sterility would appear 
to be more appropriate to these cases than to those to which Dr. Duncan 
applies it as the equivalent of comparative sterility. I venture to sug- 
gest the classification of cases of sterility into absolute and contingent, 
and each class may be subdivided into congenital and acquired. 

Cases of absolute sterility will include all those in which, from organic 
defect of the organs concerned in the formation, transmission to the uterus, 
or nidation of the ova, or in the access of the spermatic fluid, conception is 
rendered impossible. The congenital subclass of this division will include 



STERILITY 233 

cases of absence of the ovaries, or of the tubes ; of absence or non- 
development of the uterus, and of atresia of the vagina in which 
operation is impracticable. 

In the acquired subclass will come cases of a similar deficiency in the 
generative apparatus, but due to non-congenital causes, or to surgical 
operation. The cases of contingent sterility are much more numerous, and 
may also be divided into congenital and acquired. The congenital sub- 
class will include cases of defective or delayed ovulation associated with 
immaturity of the ovaries ; of certain cases of imperfect patency of the 
tubes ; of certain cases of malformation of the uterus, and especially of 
the cervix, and of such vaginal obstructions as are capable of removal. 
The subclass of cases of acquired origin will include cases Avhere patho- 
logical but remediable conditions of the ovaries, tubes, uterus, or vagina, 
inimical to conception, have occurred subsequently to birth. In this 
class would also come those cases of so-called relative sterility, to which 
reference has been made, in which a woman does not conceive with one 
husband, but does with another. An extreme case of relative sterility 
would seem to be one in which the generative organs of both husband 
and wife are normal. But obviously, after all, the explanation of rela- 
tive sterility may simply be that some abnormal and unrecognised condi- 
tion of ovary, tube, endometrium, or vagina, present during one marriage, 
may have been cured, either by nature or art, before the second is con- 
tracted. Considering the causes of sterility seriatim we have then 

I. Cases of absolute sterility in which there is (A) congenital 
organic defect of an irremediable character. 

1. hi Connection ivith the Ovaries. — The ovaries are very rarely absent 
altogether. In such cases the uterus is generally imperfectly developed 
also, and there is complete amenorrhoea. To attain a certain physical 
diagnosis of this condition is scarcely possible ; but an approximative 
diagnosis may be made if with an ill-developed uterus we find the 
association of complete amenorrhoea, the absence of any indication of 
periodic congestion, and of the special changes characteristic of puberty. 

2. Cases of absence of the tubes are occasionally recorded; but they are 
generally associated with some congenital malformation of the uterus, as 
might be anticipated from their common origin in the ducts of Miiller. 
Sometimes one tube with its cornu of the uterus is absent ; sometimes 
both. Sometimes one or both may be represented by a solid cord-like 
structure. Sometimes with a normal uterus the tube is represented only 
by a short projection from the uterine angle, and in this case the supposi- 
tion is that its condition is due to somic necrotic torsion in early or intra- 
uterine life. The diagnosis of these malformations is probably beyond 
our powers ; but if both tubes be affected an absolute sterility must result. 

3. Complete absence of the uterus is also a rare condition, but cases 
where the uterus is only rudimentary have frequently been recorded. 
In these cases it is generally the amenorrhoea which calls attention to 
the state of the pelvic organs ; and on examination by the vagina, either 
no indication of uterus is felt at its upper end, or there may only be a 



234 SYSTEM OF GYNECOLOGY 

small projection representing the cervix: on further examination by 
the bimanual method and by the rectum the uterus may be found only 
as a small body of a size varying from a ridge of the diameter of a 
crow-quill to an organ not larger than a bean. In these cases sterility 
is of course absolute. 

4. Congenital atresia of the vagina leading to absolute sterility is not 
common ; but many cases are on record where, on account of the short- 
ness of the pocket which represents the vagina, and of the anatomical 
difficulties in the way of dissection associated with the position of the 
bladder and rectum, it is not possible to open it up so as to reach the 
uterus. ISTot infrequently in these cases of abortive vagina rectal ex- 
amination will detect also a very rudimentary uterus. 

B. In the second class of cases of absolute sterility, which includes 
those of acquired origin, will come instances of somewhat similar organic 
defects, but due to pathological causes which occurred after birth, or 
ensued upon surgical operation. 

1. As regards the Ovaries. — The destruction of ovarian tissue by 
inflamma^tory, neoplastic, or atrophic disease may be so complete as to be 
incompatible with ovulation. It is presumed, of course, in these cases, 
that both ovaries are affected, and to a sufficient extent to destroy their 
capacity to ovulate. This result is not very uncommon in connection with 
pelvic peritonitis of septic or gonorrhoeal origin, or in connection with 
progressive ovarian atrophy ; it is less common in connection with non- 
septic ovaritis, or with neoplasms such as malignant, fibroid, or cystic 
growths. Occasionally the ovaries are so completely covered with peri- 
tonitic or embedded in parametric exudations that, even if ovulation 
could proceed, the ova could not escape from the follicles and reach the 
tubes. In this class would also come the results of such operations as 
double ovariotomy for ovarian cystoma, and removal of the appendices 
either for disease in themselves, or in certain cases of uterine fibroid. 

2. In connection with the tubes occur such cases as their complete 
obstruction by inflammatory pelvic exudations, or by the pressure of 
pelvic tumours, or by adhesive salpingitis or tubal tuberculosis. 

3. The removal of the uterus, either from fibroid or malignant disease, 
or by Porro's operation, would obviously be a cause of absolute acquired 
sterility. 

4. A similar result will follow complete and incurable atresia of the 
vagina by cicatricial obliteration, whether arising from sloughing due to 
a protracted labour, in connection with an exanthem, or from local injury 
of an accidental or criminal character. 

11. Cases of contingent sterility are also divisible into (A) con- 
genital and (B) acquired. 

A. Into the congenital class would come 

1. Cases ivhere the ovaries are present and free from organic disease, 
but immature ; and where ovulation is either unduly delayed, or the 
ova secreted are imperfect. With this are often associated impaired 
general health and an imperfect development of the other generative 



STERILITY 



235 



organs. TKe uterus is small, often anteflexed, the external genitals are 
of a more or less infantile character, the general signs of puberty are 
either absent or but feebly developed, and menstruation either does not 
take place at all, or occurs irregularly and scantily, and accompanied by 
much ovarian pain. But, contrary to what occurs in the corresponding 
class under the heading Absolute Sterility, in these cases, with the 
improvement of the general health an improvement may also occur both 
in the structure and functions of the ovaries ; and with the establish- 
ment of normal ovulation pregnancy may ensue. The cases of this kind 
which come under notice on account of sterility are few, the state of 
health which accompanies the sterility being often also a bar to marriage ; 
but occasionally such cases come for advice and treatment, and in some, 
improvement of the local and general conditions has been followed by 
pregnancy. In some, indeed, marriage has proved an efficient stimulant 
to an improved condition of ovaries ; menstruation and ovulation have 
become healthily established, and pregnancy has foUoAved. In a certain 
number of women, however, there is also irregular, often painful, and 
sometimes delayed menstruation ; but instead of being associated with a 
general appearance of immaturity, and more or less ill-health, the physical 
development and the general health may both be good, and the irregular 
menstruation and associated dysmenorrhcea be their only troubles. In 
many of these cases some affection of the uterus, such as a displacement 
or an endometritis, may be found on examination ; but, whether this be so 
or not, the delayed and irregular menstruation need of itself be no bar 
to marriage : marriage indeed, as in the previous case, is often followed 
by an improvement in the functions of the ovaries and occasionally by 
pregnane}'. 

2. Sterility depending upon some congenital interference of a temporary 
kind icith the patency of the tubes is probably uncommon ; but in some cases 
cysts are found in the neighbourhood of the fimbriated ends of the tubes 
which might subsequently rupture and disappear, but which, if they 
remained, would more or less interfere with the entrance of ova. Or the 
occurrence of some adhesion in the course of the tubes, due to a transient 
salpingitis which had disappeared with the progress of development, or 
to some torsion of the tube on its axis rectified by casual changes in the 
relative position of the pelvis viscera, may likewise be causes of con- 
tingent sterility. Diagnosis of these conditions would rarely be practi- 
cable, and they lie beyond the range of any treatment except perhaps an 
empirical catheterisation of the tubes, a proceeding which can hardly yet 
be spoken of as always safe or even possible. 

3. Sterility depending upon congenital mcdformaiions of the uterus 
capable of treatment is chiefly associated with those which involve the 
cervix. One such malformation is an undue elongation of the cervix, 
which is often of a conical outline, and projects into the vagina to the 
extent of an inch and a half or even two inches. The os uteri in these 
cases is generally minute in size, round or "pin-hole" in form, and is 
often placed, not centrally at the end of the cervix, but rather on one 



236 SYSTEM OF GYNECOLOGY 

side. In. a less frequent number of cases a minute os uteri is found 
associated with, a short and rounded cervix. There are also congenital 
cases of greater or less stenosis of the cervical canal without any very 
marked malformation of the cervix, the stenosis being more frequently 
at the site of the outer os, less frequently at the inner os ; in this latter 
case it is generally associated with anteflexion of the uterus. Occasionally 
there is narrowing both at the external and internal os, the intermediate 
canal being of average size ; and sometimes, but most rarely of all, there 
is a distinct constriction in the canal itself. The relation of stenosis of 
the cervix to the production of dysmenorrhoea is a much-debated sub- 
ject, and need not be entered upon here ; but of its influence as a factor 
in the production of sterility I have no doubt. The accumulated clinical 
evidence in favour of the view that the removal of stenosis facilitates 
impregnation is, I believe, decisive. I have known some cases in which 
a single dilatation after an unfruitful marriage of many years' duration, 
varying from five to fifteen, has been followed by pregnancy ; and a con- 
siderable number in which a series of dilatations, as may be required by 
the conditions of the case, has been followed by a similar result. Such 
cases are also recorded by Duncan. Yet, of course, this result may not 
follow even after complete dilatation has been accomplished ; the strong 
probability in such cases is that some other pathological factor, besides 
the cervical stenosis, is present. But even if this be so, the removal of 
the stenosis is a useful as well as a logical proceeding, as it assists in the 
cure of any other conditions present which may be antagonistic to im- 
pregnation. For instance, the cervical stenosis may have led to dysmenor- 
rhoea, or it may be associated sequentially with some congestive condition 
of uterus, tube, or ovary, either of which disorder in its turn may be a 
cause of sterility. With the relief of the dysmenorrhoea this sequence of 
congestions may subside, and as a result the influences hostile to concep- 
tion may disappear. On the other hand, the endometritis or salpingitis or 
ovaritis, of which the narrowed cervical canal was the primary cause, 
may have been of such long standing, and accompanied by so much tissue 
change, that even after the cervical canal has become normal, it may 
be difficult or impossible to bring about a sufficiently healthy condition 
in the uterus or in the ovaries to permit conception. 

A hypertrophic elongation of the cervix is an occasional congenital 
defect ; and, as it simulates prolapsus uteri, it is sometimes called infra- 
vaginal prolapse. In these cases the cervix is sometimes so unduly 
elongated as to reach down to, or even to pass beyond the vaginal orifice, 
and thus to give rise at first sight to the impression that the case is one 
of ordinary prolapse. Sometimes this condition has not been noticed 
before marriage, as it causes little or no inconvenience, unless it be some 
sense of bearing down, and some dysmenorrhoea. But after marriage it 
becomes a source of marital inconvenience, and the surface becomes 
inflamed and possibly excoriated. That it is not an ordinary prolapse 
is proved by the use of the sound ; and by the normal position of the 
body of the uterus in the pelvis, as shown by bimanual examination. Its 



STERILITY 237 

removal by amputation removes both, the dyspareunia and a cause of 
probable sterility. Fertilisation in these cases is perhaps not impossible, 
but I have seen several such cases, and in none did impregnation take 
place prior to the removal of the elongated cervix. 

4. Cases of contingent sterility of congenital origin include malfor- 
mations of the vagina and of its vulval entrance. 

An imperforate hymen is at once a barrier to intercourse and to 
conception. A cribriform hymen, or an unusually thickened annular or 
crescentic hymen, may also render intercourse difficult, and so may im- 
pede the occurrence of conception ; but it would not necessarily lead to 
sterility. Occasionally, also, we meet with cases in which a transverse 
septum exists a third or a half way up the vaginal canal. Such a 
septum, if imperforate, might permit intercourse, but would obviously 
prevent conception ; yet if an opening were present in it, permitting 
the exit of the menstrual secretion, conception would be at least possible, 
although if the opening were a minute one it would not be probable. 
These diaphragms probably arise from some limited adhesive inflamma- 
tion of the vaginal walls in very early life ; and there are grounds for 
supposing that imperforate hymen itself is due to adhesive inflamma- 
tion, in early or even in intra-uterine life, uniting the free edges of an 
annular hymen. In both cases the division of the hymen or the division 
of the septum is necessary. Occasionally the vagina terminates in a 
cul-de-sac, and between this and the uterus a greater or less thickness 
of cellular tissue is interposed, with the bladder in front and the rectum 
behind. In many of these cases, as stated under the heading of 
absolute congenital sterility, to dissect through this tissue to the uterus 
has, for the reasons there given, proved difficult or impossible : in some 
cases, however, the dissection has been attempted with success ; and 
if the uterus, tubes, and ovaries be healthy, conception becomes possible. 
Sometimes that rare condition, a double vagina, may be a cause of 
sterility. If associated with a double uterus and bifid cervix, with one 
cervix projecting into each vagina, the sterility may arise rather from 
the imperfect character of the uterus and of the cervix, the two halves of 
which are often abnormally developed, than from the divided vagina 
being a barrier to intercourse. One cervix may be quite short and 
rudimentary, while the other is of average size ; and in one or both the 
OS is apt to be situated laterally, and to be very minute or of an 
irregular outline. 

Cases are also met with in which the two vaginas are so narrow as to 
make sterility probable, by preventing effective intercourse ; a difficulty 
to be removed by the division of the intervening septum so as to throw 
the two into one. In such a case, if the uterus and organs beyond be- 
normal, there is no further barrier to conception ; but more commonly 
the uterus shares in the malformation. Occasionally one vagina is of 
average size and the other much smaller. Vaginismus may possibly be 
a congenital cause of contingent sterility ; but as it is more frequently 
of acquired origin it will be considered further on. 



238 SYSTEM OF GVNyECOLOGV 

B. Acquired Contingent Sterility. 

1. From Abnormal Conditions of the Ovaries. — The ovaries may be so 
damaged by acute or chronic ovaritis that for a time the Graafian follicles 
do not mature normally, and ovulation is either performed imperfectly 
or not at all. But in the cases belonging to this class the damage is 
not irretrievable. With a return to a healthy condition of the ovary, its 
function is restored and the possibility of conception returns. Subacute 
ovaritis may arise from the lesser attacks of septic or gonorrhoeal in- 
fection, from limited congestive haemorrhage into the structure of the 
ovaries, from a chill during menstruation, or in association with endo- 
metritis and backward displacements of the uterus. It will of course 
be understood, as in the other classes of cases in vfhich the condition of 
the ovaries is the cause of sterility, that sterility only occurs when both 
ovaries are affected. But from many of the causes just enumerated 
both ovaries do become involved, though often one more markedly 
than the other ; not infrequently after an attack of double ovaritis, one 
ovary, usually the right, will apparently recover completely, so far, 
at least, as can be judged by examination, while the other remains 
tender, swollen, and possibly displaced. And in many of these cases 
there is sterility, although apparently one ovary is healthy. The 
probability in such cases is that recovery is incomplete, and that the 
inflammatory attack, to which one ovary has succumbed, has also 
brought about some change in the structure of the other which cannot 
be estimated by a bimanual or other examination. Possibly also func- 
tional disturbance in one may be sympathetic with structural change 
in the other. In addition to ovaritis other affections of the ovaries 
have been referred to under the head of absolute sterility which, if 
less serious in extent and character, may be only temporary causes of 
sterility. Such would be cases of pelvic peritonitis in which peritonitic 
exudation, instead of forming an impenetrable investment to the ovary, 
is slighter in character, and after a time becomes sufficiently thin to 
yield to the distension of a maturing Graafian follicle, and to permit the 
ovule to pass through and reach the tube. Or a parametric exudation, 
which has pressed upon and covered up one or both ovaries for a time, 
may be so absorbed as to permit their function to be restored ; or possibly 
even cystic disease may be present, but to so limited an extent that 
healthy tissue sufficient for ovulation remains. Temporary malposition 
of the ovaries, the result of an ovaritis which has led to enlargement and 
increased weight, and so to more or less prolapse, or the downward 
displacement of both ovaries which often accompanies retroversion and 
retroflexion of the uterus, may be a cause of difficulty in the way of the 
ova reaching the tube, and so lead to a temporary sterility. And, lastly, 
apart from tissue-changes and displacements, the ovaries may share in 
a general condition of depressed innervation, and perform their function 
as imperfectly as do other organs of the body under similar conditions 
of general health, whether these conditions be associated with anaemia 
or plethora, or some more serious morbid diathesis. Their innervation 



STERILITY 239 



and blood-supply being faulty, the ova tliey secrete will be faulty too ; 
and sterility will continue until, with improved health, their condition, in 
common with that of other organs of the body, becomes normal and their 
function is normally performed. 

2. The pathological conditions of the tubes which lead, while they 
continue, to sterility, would include the slighter forms of double salpingitis, 
generally of septic or gonorrhoeal origin, which terminate without 
rendering the tubes impermeable, whether by internal adhesions or by 
distension with serous, sanguineous, or purulent collections. Mechanical 
interference with the tubes by pressure from some pelvic tumour would 
cease as a cause of sterility ; either by removal of the latter (were it 
undertaken for any reason), or by some such shifting of its posi- 
tion as might occur with either a pediculated fibroid or an ovarian 
cyst. 

3. But much more frequent and so more important than any affections 
of the tubes in leading to contingent sterility are certain diseases of the 
uterus. And chief among these are endocervicitis,endometritis,Sind. metritis. 
The influence of a severe and established endocervicitis in favouring steril- 
ity is well marked. The swollen and abraded lining membrane and the 
tenacious muco-purulent discharges offer together a distinct obstruction 
to the ingress of spermatozoa, while the character of the inflammatory 
discharges is prejudicial to their life. The word obstruction is used here 
in its widest sense; it is not limited simply to mechanical obstruction, 
but includes whatever obstacles may be offered by the hypersemic con- 
dition of the tissues of the cervix to that physiological dilatation of the 
canal which favours the ascent of the spermatozoa into the uterine cavity. 
That the obstructive influence of endocervicitis is not simply hypothetical 
is supported by extended clinical evidence and the observations of 
numerous authors. Repeatedly on the cure of endocervicitis pregnancy 
has ensued in a patient previously sterile. With slighter attacks of mere 
cervical catarrh, which is an extremely common malady, the hindrance 
to conception is proportionately less. With chronic endometritis, if this 
term be applied to inflammation of the lining of the uterine cavity, the 
influence on sterility is somewhat different ; for, on account of the swollen 
condition of the endom.etrium, there is probably also obstruction to the 
ascent of the spermatozoa through the uterine cavity, and to their 
entrance into the tubes ; especially if the membrane around the orifices 
of the tubes be involved. The inflammatory secretions of the cavity are 
also inimical to the life of the spermatozoa ; while a further effect of 
endometritis is the strong tendency which exists with it to abortion on 
account of the diseased endometrium failing to offer a safe nidus for the 
support and sustenance of the ovum. The forms of endometritis known 
as membranous and villous, and that due to syphilis, are particularly 
hostile to the occurrence of pregnancy ; and if conception should occur, 
abortion is almost certain. 

In chronic metritis it is probable that the tissue of the uterus is never 
affectedwithout the endometrium being also involved, either in the interior 



240 SYSTEM OF GYNECOLOGY 

of the body or in the cervical canal, or in both. In endometritis, on the 
other hand, the muscular tissue immediately subjacent to the mucous 
membrane may only be affected ; but it is often the starting-point of a 
general metritis, aided by abnormal states of the general health, and by 
certain conditions of the portal system and heart which lead to pelvic 
hypersemia. However started, metritis, when chronic, becomes a well- 
recognised cause of sterility. The term metritis, without reference to 
the disputed point whether the muscular fibres of the uterus are capable 
of inflammation in the strictly scientific sense, is here used to include 
the results of chronic hypersemia in the increase of connective tissue 
formation ; and to include also the condition sometimes spoken of as 
subinvolution of the uterus, which I believe to be essentially a chronic 
metritis whose starting-point has been some traumatic or septic influence 
connected with labour. In these conditions of uterus the sterility 
which frequently accompanies them is due not merely to the endometrial 
changes already referred to, which interfere with fertilisation and dis- 
pose to abortion, but to the slow inflammatory changes which spread 
to the tubes and ovaries, which interfere with ovulation or with the 
transit of ova through the tubes, and, if complete, remove the case from 
the hopeful to the hopeless class. Hyperplasia limited to the cervix 
would affect impregnation in so far as the calibre and the condition of 
the lining membrane of the cervical canal are affected, and in proportion 
to the loss of elasticit}^ in the tissues of the cervix itself. 

Versions and Flexions of the Uterus. — In cases in which the uterus 
is simply displaced, either backwards or forwards, without any bend on 
its own axis, if there be no associated metritis or endometritis, I do 
not think such displacements would have much hostile influence on 
conception, unless a backward position of the fundus with the os directed 
towards the anterior vaginal wall should interfere with the access of 
spermatozoa into the cervix, or should also cause a displacement of the 
ovaries from their normal relation to the fimbriated ends of the tubes. 
Possibly also displacement may, in intercourse, prevent that adaptation 
of the cervix to the male organ which some writers hold to be favourable, 
if not essential, to impregnation, and which by Eainey was believed to 
be brought about, under normal circumstances, by the action of the 
round ligaments. But cases of version without flexion are comparatively 
few, at all events as regards cases of retroversion, which, unless as a stage 
of prolapse, is rarely seenwithout some associated flexion. When versions 
exist there is a tendency to progressive uterine hypersemia with the 
results, as regards conception, indicated under metritis. But where 
flexion is added to version and the uterus is bent on itself, the tendency 
to the dysmenorrhoea of uterine colic is rarely absent, and more or less of 
endometritis and chronic metritis result. 

Anteversion and anteflexion are recognised as but an exaggeration 
of the normal state and position of the uterus in early life, prior to 
puberty ; and, in cases in which this condition persists, the uterus as 
a whole not infrequently remains infantile in character with a small 



STERILITY 241 



pointed cervix and a minute os. In these cases djsmenorrlioea is the 
rule, and not infrequently amenorrhoea more or less complete, showing 
probably an immature condition of the ovaries also ; should marriage 
take place, sterility is almost invariable. But these cases are not hope- 
less. Both by medicinal and local treatment the condition may be 
improved, normal menstruation become established, and the uterus and 
its appendages may take on a distinct if slow improvement. It has been 
stated that in rare cases versions may exist without any associated 
flexion ; but still more rarely, if ever, is there flexion without some co- 
existing version. And as with anteflexion there is generally anteversion, 
so with retroflexion there is almost invariably retroversion ; but contrary 
to what obtains in anteflexion, retroflexion is rarely congenital. It is 
comparatively rare in the nullipara, but in the multipara very common ; 
and this is so because its most frequent starting-point is to be found in 
the conditions of the puerperium. Its influence on sterility is twofold : 
firstly, the flexion as a rule produces a virtual stenosis of the cervix, 
which constitutes an initial difficulty in the way of impregnation. In 
cases in which with flexion there is no stenosis this difficultj^ of course 
does not occur; but where there is stenosis dysmenorrhoea is rarely 
absent ; and in its train come, secondly, endometritis and chronic uterine 
hyperaemia with leucorrhoea, menorrhagia, and, as a rule, sterility. It 
has frequently happened that on reposition of the uterus and its subse- 
quent return to a healthy condition, pregnancy has resulted even after a 
long interval of sterility. It must not be forgotten, also, that if pregnancy 
occur in cases where some retroflexion exists, but in which the uterus 
continues fairly healthy, there is always a risk of its premature termination 
by incarceration of the fundus in the sacral cavity, and by the pathological 
changes which then ensue. The last displacement to be noticed in con- 
nection with sterility is prolapse. In the various degrees of incomplete 
prolapse of the uterus there is not much interference with the possibility 
of conception if the organ itself continue healthy ; but if prolapse be- 
come associated with chronic metritis, a tendency to sterility, in propor- 
tion to the extent of the metritis, will ensue. In complete prolapse 
endometrial and metritic changes are generally present which, if impreg- 
nation took place, would militate against a normal continuance of the 
pregnancy. But the majority of these cases of complete prolapse occur 
in women who have passed the usual limits of child-bearing. 

Occasionally an elongation of the cervix takes place in women after 
child-birth, which appears to be secondary to congestive changes in the 
cervix resulting from some pathological incident of labour, and resembling 
in character those cases of congenital elongation, or infra- vaginal prolapse, 
which have already been considered. In these the tendency to sterility 
is not so strongly marked as in those of congenital origin ; but from the 
accompanying endometrial changes there is a distinct tendency to early 
abortion, and so practically to sterility. 

Of the uterine tumours which jyromote sterility those requiring the chief 
consideration Sive Jibroids ; and their precise influence, as regards sterility, 



242 SYS 7^ EM OF GYNECOLOGY 

will depend not only upon their size and position, but also upon the local 
changes they produce within the pelvis. Subperitoneal pediculated 
fibroids by themselves, if the uterus be otherwise healthy, will not 
necessarily interfere with impregnation, nor perhaps with the process of 
pregnancy, although there must always be the possibility that by some 
casual twist of the pedicle uterine disturbance may be set up, and prema- 
ture labour either come on or even require induction if any symptoms of 
strangulation of the fibroid occur. A case of this kind occurred in my 
experience where, even after pregnancy and delivery had been safely 
accomplished, an accident led to partial severance of a pediculated 
fibroid, followed by intraperitoneal haemorrhage and peritonitis, which 
necessitated abdominal section, and hysterectomy. 

When fibroids are situated in the uterine wall they may have an 
obstructive influence on the possibility of impregnation if their situation 
be in or near the cervix, and they press upon, distort, or harden the canal. 
This, however, is their least common position. But not infrequently, if 
in the anterior or posterior wall, they will also affect the canal, though 
to a less degree ; sometimes, however, in the case of multiple fibroids to a 
very high degree, the uterine tissue around and between the fibroids being 
dense and unyielding in character. But supposing this not to be so, and 
that they do not interfere with the physiological dilatation of the canal, 
and that impregnation occurs, there is still the great probability that the 
highly vascular and hypertrophied lining membrane, which coexists with 
a fibroid projecting into the interior, and the resulting menorrhagia, 
may prevent the normal fixation of the ovum. Even if these initial 
difficulties do not occur, and the ovum continue to develop, there are yet 
great probabilities of early abortion or premature labour. 

And beyond the influence upon the prospects of pregnancy due to 
the effects of fibroids upon the uterus itself, we have also to con- 
sider the effects of pressure exerted by them upon the other pelvic 
viscera, including the tubes and ovaries ; especially if the tumour be 
large, or if it be multiple. Under these circumstances the ovaries are 
not infrequently displaced and pressed upon, and the tubes twisted 
or flattened ; and often also more or less pelvic peritonitis supervenes, 
leading to adhesions and matting together of many of the pelvic 
contents. 

In the case of polypi a pediculated submucous fibroid thus projecting 
into the uterine cavity has a twofold influence upon the causation 
of sterility. If the cavity of the uterus be much enlarged, and if the 
polypus spring from the fundus and press upon the orifices of the tubes, 
there is a difficulty in the way of the spermatozoa either reaching or 
entering the tubes. However, supposing this not to occur, and fertilisa- 
tion to take place, a difficulty might arise in the passage of the fertilised 
ovum into the uterine cavity. It is believed, indeed, that in some 
cases such obstruction has been a cause of tubal gestation. Supposing, 
lastl}^, neither of these obstructive difficulties to occur, there would still 
be the endometritic condition of the lining membrane of the uterus to 



STERILITY 243 

contend with, kept up by the presence of the polypus and its attendant 
leucorrhoea and menorrhagia, both highly provocative of abortion. 

In the case of cervical mucous polypi the tendency to sterility is partly 
from the obstruction offered by the polypus itself which may act like a 
ball-valve against the ingress of the spermatic fluid, and still more from 
the catarrhal condition of the cervix. In the case of large fibroid polypi 
projecting through the cervix and filling the vagina, sterility is almost 
certain until the removal of the polypus has made impregnation possible. 

In carcinoma of the uterus in the early stage, Avhether the disease have 
attacked the vaginal aspect of the cervix or the cervical canal, sterility is 
certainly not absolute. Pregnancy in such conditions occasionally occurs. 
But in the later stages, when the cervix is the seat of a soft, friable, and 
easily bleeding papillary growth, or when its canal is filled with a soft 
vascular growth, or is excavated and granular, or again when the body 
of the uterus is affected, pregnancy is unlikely. In many cases of 
cervical carcinoma, in which pregnancy has occurred, the amount of the 
disease at the date of fertilisation was probably not large ; for its growth 
is largely stimulated by the heightened uterine vascularity which accom- 
panies gestation. The causes of the sterility in the majority of cases 
of carcinomatous cervix are perhaps partly mechanical, according to the 
extent to which the cervix was occupied with cancerous growth, and 
partly the effect of cancerous discharges on the vitality of the spermatozoa. 
In many cases, also, intercourse is followed by so serious and sometimes 
by so alarming a haemorrhage that there is but slight prospect of fertil- 
isation. In cases in which impregnation does take place there is always 
a tendency to abortion. 

4. Lastly, in the vagina and vulva causes of sterility are not infre- 
quently met with. Vaginitis may be a factor in the causation of a tem- 
porary sterility, both by rendering intercourse too painful to be borne, 
and by the excessive acidity of the inflammatory secretions being fatal 
to the spermatozoa. Undue shortness of the vagina and a ruptured peri- 
neum may also interfere with the proper retention of the seminal fluid. 

Tumours of the vagina, even if innocent like cysts or fibroids, offer 
a mechanical obstacle to normal intercourse, and also, by provoking 
an excessive leucorrhoeal discharge, endanger the vitality of the sper- 
matozoa. In sarcoma and carcinoma of the vagina there is an additional 
adverse factor in the frequent haemorrhages and, ultimately, in the 
necrotic discharges which occur with the advance of the disease. The 
presence of a vesico-vaginal fistula is not necessarily, perhaps, a cause of 
sterility, but the probability of its being so is considerable. 

Certain diseases of the vidva are mainly operative by way of 
dyspareunia, which either prevents marital intercourse altogether, or 
renders it less eflicacious for fertilisation. Such are vulvitis, especially 
if it be of the follicular type and accompanied by scattered small ulcera- 
tions generally superficial in character, but highly sensitive to any touch. 
Ci/stic enlargement or abscess of one of the glands of Bartolini generally ren- 
ders intercourse impracticable until it is cured. Eczema affecting the labia 



244 SYSTEM OF GYNECOLOGY 

majora, with which is often associated a sensitiveness so acute that even 
sitting is painful, often renders any attempt at intercourse impossible. 
Pruritus, whether inflammatory or neurotic, is likewise a cause of steril- 
ity in proportion to the dyspareunia it produces ; and this it is partic- 
ularly apt to do, as the clitoric area of the vulva is generally chiefly 
affected. Caruncle of the urethra is another and very persistent cause 
of dyspareunia. So exquisitely sensitive is it in some cases that even 
the passage of urine gives extreme pain, and intercourse is impossible. 
Occasionally on the vulva, and not infrequently on the remains of the 
hymen, are found little bright red vascular patches of an extreme sensi- 
tiveness. Not infrequently these are gonorrhoeal in origin, and found in 
association with inflammation of the orifices of the ducts of Bartolini. 
These patches are exquisitely sensitive, and are very generally barriers to 
intercourse. Hypertrophic enlargement of the labia majora, or, more rarely, 
of one or other nympha, has occasionally been so considerable as to inter- 
fere with intercourse. And, lastly, there is the condition termed vagi- 
nismus, by which is understood a spasmodic contraction of reflex origin 
of the muscular fibres surrounding the vulval orifice of the vagina. In 
a few of these cases, and for the most part in patients of a highly neurotic 
type, no local abnormality can be detected; but in the majority local 
pathological conditions are present which induce more or less violent 
spasm of the sphincter on the least touch. Whether the hyperaesthesia 
be neurotic, or dependent upon some obvious pathological condition, the 
resistance in some of the worst cases to any attempt at intercourse is 
extreme ; the spasmodic contraction at the vaginal entrance is violent, 
and, if the attempt be persisted in, epileptiform convulsions or attacks 
of syncope may occur. In these severer cases sterility is, of course, 
invariable. Occasionally these cases come before the courts of law as 
a ground for divorce, and I gave evidence in one such case in which, 
for the first time in English law, a divorce was granted for what was 
but a virtual obstacle to the consummation of marriage. Any attempt 
at intercourse rendered the respondent for the time being practi- 
cally maniacal. Among the pathological conditions which are more 
usually found to coexist with and to induce this singular sensitiveness 
are an undue rigidity of the hymen, an inflamed condition of the 
membrane occurring either before or after its rupture, unhealed fissures 
of the hymen following its rupture, eczema of the vulva, and small 
ulcers about the inferior vulval commissure or at the edge of the peri- 
neum, vascular excrescence of the urethra, fissure of the anus, and 
occasionally some form of uterine displacement or periuterine inflamma- 
tion. 

It will be understood, of course, that these contingent cases differ 
from those of the absolute class, in that there is always the possibility 
of impregnation in spite of the existing pathological conditions. If in 
spite of a vaginismus insemination occur at the orifice of the vagina, 
it is quite possible for spermatozoa to reach the uterus, and under 
favourable circumstances fertilisation may be effected. And in the case 



STERILITY 



245 



of a cervical catarrh, attended with tenacious and obstructive discharge, 
occasionally the canal may be fairly healthy, may be free from dis- 
charge, may permit a normal dilatation, and fertilisation become possible. 

In the case of vaginismus, again, especially where the cause is neurotic, 
the pain and consequent dread felt at one time may be absent at another. 
I have known more than one case where sometimes on attempt at inter- 
course the patient has not only resisted but violently attacked her hus- 
band, while on other occasions she has received him without opposition. 
In one case of the kind the patient would sometimes spring out of bed at 
her husband's approach, while at another time she would be quiescent 
and unresisting. 

It may be stated here that neither sexual desire nor sexual pleasure 
is essential to impregnation. Impregnation has been known to follow 
criminal and forcible assaults, with fright and horror and suffering as 
their necessary concomitants. It is also certain that desire may exist 
without any pleasure in intercourse, and that pleasure may occur with- 
out desire. Under various circumstances, such as unhappiness in the 
relations between husband and wife, any feeling of desire may be in 
abeyance, and yet the act itself be pleasurable; and sometimes, even 
if there be a strong feeling of antipathy to the generative process al- 
together, the act itself may not be unattended with pleasure. On the 
other hand, desire may exist, but from the presence of some of the 
pathological conditions named any feeling of pleasure may be more than 
neutralised by pain and suffering. Occasionally we meet with patients 
in whom there is neither desire nor pleasure, who are always apathetic 
and passive. But in all these cases, whether desire or pleasure or both 
be absent, fertilisation may occur. In several cases in which one or 
other or both of these defects were present in Avomen in whom pregnancy 
had not occurred, I have found some condition present which, while 
insufficient, perhaps, to render intercourse actively painful, has evidently, 
and in a way difficult to explain, interfered with its pleasure : the ex- 
planation may be that any faulty link in the chain of incidents which 
constitutes the entire generative process may interfere with the com- 
pleteness of those physiological sensations which accompany its initia- 
tion. And still further, I have known several sterile women, with a 
more or less active dislike of intercourse, and to whom it gave no pleas- 
ure, who found both pleasure and desire after some pathological condition 
was remedied, such as a cervical stenosis by dilatation, or a retroflexion 
of the uterus by replacement. But although desire and pleasure are not 
essential to impregnation, there can be no doubt that they are favourable 
to its occurrence, as showing that the organs concerned are healthy, and 
their function likely to be healthily performed. The absence of pleasure 
is probably, therefore, significant of some pathological condition ; al- 
though it is quite possible that to ascertain in what it consists may in 
many cases be beyond our diagnostic powers and beyond the application 
of any remedy. Excess of sexual excitement, on the other hand, is 
prejudicial to fertility in so far as it induces certain pathological 



246 SYSTEM OF GYNjECOLOGY 

results, such as a sustained congestion of the uterus and its appendages, 
leading to ovaritis, and with it to defective ovulation ; or to salpingitis, 
and with it to more or less obstruction to the descent of ova and the 
ascent of spermatozoa ; or to metritis, and with it a tendency to the 
occurrence of abortion. 

With the treatment of these various pathological conditions this 
article does not deal : this is discussed in other sections of this System 
in connection with the several pathological conditions. In cases of 
absolute sterility, whether congenital or acquired, there is, of course, 
from their very nature no treatment possible ; but in the larger number 
of the contingent cases much may be hoboed for from successful treat- 
ment. Here the question of diagnosis is of the essence of success : yet 
in many cases it is beyond our powers. A very slight change, for 
example, in the mutual relations of ovary and tube, quite beyond our 
capacity to diagnose, may prevent ova entering the tube and allow them 
to drop into the peritoneal cavity and be lost ; or a faulty condition 
of the ovary itself, depending possibly upon some defective local inner- 
vation, and beyond the scope of any possible physical diagnosis, may be 
the cause of imperfections in the ova. In a great many cases, however, 
a painstaking investigation will disclose some faulty link in the chain 
which connects insemination with fertilisation. We must also remember 
that the causes of sterility may be multiple ; and that, because one has 
been removed without the occurrence of pregnancy, it is not necessary 
to regard the case at once as hopeless. A cervical stenosis may be cured 
by appropriate dilatation, and yet imperfect ovulation, depending on 
a chronic ovaritis or the condition of the general health, may remain. 
A dyspareunia, sufficient to prevent intercourse, depending upon the 
presence of a vascular caruncle of the urethra, or an inflamed hymen, 
may be cured by the removal of the caruncle or the relief of the local 
inflammation ; and yet conception may not occur because of a viscid 
catarrhal discharge blocking the cervical canal, or of a gonorrhoeal sal- 
pingitis which has resulted in tubal stenosis. It must not, of course, 
be forgotten that in a certain number of cases (variously estimated at 
from eight to fifteen per cent) it is the husband who is at fault ; but of 
the nature and cause of these faults no consideration is undertaken in 
this article, which is written from the point of view of the gynaecologist, 
and treats only of the pathological conditions with which he has to deal. 

A few words may be given to the consideration of certain remedial 
measures which may be proposed, often somewhat empirically, either 
without a sufficiently careful investigation of the possible causes of the 
sterility, or after such investigation has disclosed nothing obviously 
wrong. Certain watering-places are frequently recommended as cures 
for sterility, and in many cases the desired result has been obtained ; 
but probably only when the waters happen to be adapted to the cure of 
the pathological condition on which the sterility depends. 

Where some chronic congestion of the pelvic viscera, associated with 
a gouty diathesis or liver troubles, indicates an alkaline and saline treat- 



STERILITY 



247 



ment, Brides les Bains, Kissiugen, and Ems may be nseful. Where some 
l^revious inflammatory attack has produced parametric thickening of the 
]3road ligaments, with associated subovaritis and metritis, the waters of 
Kreuznach are of distinct value. In cases of uterine fibroids their value 
would appear to be less. Where ansemia exists, with scanty catamenia, 
impaired general health, and probably imperfect ovulation, the waters of 
Franzensbad, of Schwalbach, of Pyrmont, and of Spa are indicated. The 
Marienbad waters, including, as they do, both alkaline and ferruginous 
springs, can be resorted to accordmg to the indications of the case \yide 
art. " Balneology," Syst. of Med. vol. i. p. 318]. And, lastly, if the gen- 
eral health be at fault, and more esjjecially the nervous system, with- 
out any predominance of ansemia or obvious pelvic mischief; and if 
there be a dyspareunia, of neurotic origin, a residence for a time in 
mountain air has been found beneficial. 

As to medicines for sterility, apart from such as influence its recog- 
nised pathological causes, there is probably none of any certain value : 
but possibly in some cases where, without organic defect or functional 
disorder or impaired general health, there may be some limited failure 
of ovarian innervation, and so a secretion of defective ova, the use of an 
ovarian extract may be tried in the same way as thyroid or thymus or 
splenic extracts have been given in cases of defective function in the 
corresponding glands. 

Of artificial fertilisation it need only be said that Sims, who wrote on 
this subject, appeared at one time to have much hope from its adoption ; 
but during two years, in which he carried out fifty -five injections, he 
succeeded in one c^se only, and in this an early miscarriage occurred. 
He subsequently gave up the practice, and no writer has advocated it siuce. 
The least that can be said about such a suggestion is that it is wholly 
empirical. The cause of sterility being, in the great majority of cases, of 
the contingent class of pathological origin, its remedy is to be sought 
rather in minute diagnosis. 

Many of the causes named are so slight in themselves, and of such 
slight importance to the patient's health, that unless she seek advice on 
account of her sterility she may consider herself in good average health ; 
and without any local defect likely to be a cause of sterility. A per- 
sistent but not excessive leucorrhoea, a moderate d3^smenorrhoea, a 
tendency even to menorrhagia, may all be thought of little importance, 
or not sufficiently important or unusual to need advice ; and yet may 
be the indication of a pathological condition adequate to account for 
sterility. 

Two or three points in connection with the subject generally remain 
for consideration. Obesity has been held to be adverse to fertility, but 
without any very decided observations to support the opinion. Probably 
its concurrence with sterility may be due to pathological conditions which 
exist with the obesity, or as its result, rather than to the obesity itself. 
With obesity not infrequently both portal and cardiac disorders, suffi- 
cient to lead to pelvic congestion, are associated; and, as a result, dis- 



248 SYSTEM OF GYNECOLOGY 

tui'bed function of the pelvic organs would follow. There would also be 
the possibility of a heavy omentum pressing upon the pelvic contents, 
and interfering with the normal relation between the ovaries and 
tubes. 

Tlie injiuence of alcohol in excess is also held by some to be adverse 
to fertility ; if so, this would probably rise from a somewhat similar 
series of pathological incidents. Following upon portal congestion would 
come congestion of the pelvic viscera, with its various adverse possibilities 
in connection with a fertile ovulation ; and there would also be a gradual 
deterioration of the general health, leading to disordered innervation and 
to inefficient performance of the functions of the body generally. 

Excess or deficiency of menstruation is regarded by some writers as 
unfavourable to fertility. Impregnation may certainly take place whether 
the catamenia be profuse or scanty ; but both these extremes point to 
some pathological condition of the uterus or its appendages, or to some 
disorder of the general health which may be unfavourable to con- 
ception. 

The marriage of near relations has also been held to be adverse to 
fertility, but probably without any very good grounds; and when in 
such a case a sterile marriage has resulted it would probably be explicable 
by some pathological tendency common to both husband and wife, and 
affecting in a similar way the various functions of the body, and among 
them those of the generative system. If both husband and wife, 
though related, are free from any common diathetic taint, and of aver- 
age health, there is no reason why sterility should attend their union. 
Marriage with heiresses has been regarded by some writers as undesirable 
from the point of view of fertility. If an heiress be the sole survivor of 
a family (and the fact of her being an heiress in many cases signifies as 
much), this circumstance may indicate some family pathological tendency 
which has led to the premature deaths of other members of the family: 
these tendencies she may share, her generative in common with her other 
functions may be abnormally performed, and her marriage from the 
point of view of fertility may be undesirable. But if she have become 
an heiress less as a result of an undue pathological mortality among the 
members of her family than from accidental circumstances, such as the 
chances of travel, war, or epidemics, and if her health be good, there 
would appear to be no very valid reasons against her marrying, even if 
the perpetuation of a family name were specially desired. 

In conclusion it may be remarked that, although with the lapse of 
every succeeding year after the third from marriage, without the occur- 
rence of conception, the prospect of child-bearing becomes less, yet if no 
obvious cause of sterility be discoverable, either absolute or contingent, 
the patient may still be encouraged to entertain some hope. There are 
sufficient cases on record of conception occurring after a marriage sterile 
even for fifteen or twenty years, to prevent entire despair ; a slight change 
in the mutual relation of the pelvic viscera ; a slight improvement in 
some local innervation ; a subsidence of some little chronic congestion in 



GYNECOLOGICAL THERAPEUTICS 249 

ovary, tube, or uterus, even after the lapse of many years, may rectify 
the minute pathological condition on which the sterility depended. 

Henry Gervis. 

REFERENCES 

1. Barnes, Robert. Diseases of Women, 1878. — 2. Budin, Paul. Ohstetriqiie et 
Gynecologie Recherches diniques, 1866. — 3. Doran. Tumours of the Oua?^, 1884. — 4. 
Duncan, J. Matthews. On Sterility in Women, 1884. — 5. Ibid. Fecundity, Fertility, 
Sterility, 1866. — 6. Galton, Francis. Hereditary Genius, 1867. — 7. Scanzoni, F. W. 
VON. Diseases of Women. Translated from the French of Dor and Socin, 1861. — 
8. Sims, J. IVIarion. Clinical Notes on Uterine Surgeinj, 1866. 

H. G. 



GYNAECOLOGICAL THEEAPEUTICS 

It is a mistake to treat Gynaecology as a narrow specialism. Successful 
treatment of pelvic disorders depends upon a correct view of the organic 
and functional integrity of the other organs of the body. It involves 
also a somewhat close investigation, and very often considerable modi- 
fication of the habitual regime of the patient. In other words, it is 
based on general principles as well as on local lines. 

The successful gynaecologist is not one who treats the pelvic dis- 
order as an isolated event, but who views it either as arising out of an 
existing (or pre-existing) constitutional state, or faulty regime of the 
patient; or, if purely local in its origin, as likely sooner or later to 
injure the general health. 

Frequently we have to deal with a " ^'icious circle," with local and 
constitutional states so interacting, that no real improvement is pos- 
sible until the " circle " is broken, and both the general and local states 
receive their due shares of attention. 

Thus the circulation, the digestion, and the other important systems 
may influence or be influenced by the pelvic organs ; and the woman 
must be treated as a whole, able only to enjoy perfect health as regards 
one set of organs, when all her other organs are equally healthy. 

Professor Clifford Allbutt has drawn attention to the influence of the 
nervous system on the symptomatology and treatment of Gynsecology. 
He says " the uterus has its maladies of local causation, its maladies of 
nervous causation, and its maladies of mixed causation, as other organs 
have." This element of neurosis it is which, whether cause, complica- 
tion, or effect, tends to baffle the gynaecologist ; and, if disregarded, will 
prevent the complete cure of a patient whose pelvic organs seem to have 
regained their organic and functional integrity ; especially if attention 
have been paid correctly, but too exclusively, to these viscera. 

Instances of such complexity could be multiplied indefinitely, but 



250 SYSTEM OF GYNECOLOGY 

would merely serve to emphasise the fact that general therapeutics are 
essential to the efficient treatment of almost all cases which, owing to 
the predominant, or perhaps the almost exclusive, pelvic character of 
the symptoms, come, correctly enough, under the term " gynaecological." 

Notwithstanding this, it is obviously impossible to do more than 
to indicate briefly those therapeutic methods which are immediately 
pelvic in their application ; and the more general methods must be 
rigidly omitted from consideration. 

The subject of Gyncecological Therapeutics may be discussed under the 
following subdivisions : — 

1. General Hygiene (Routine, Clothing, Diet, Baths, Exercise, etc.). 
2. Rest (General, Local, Physiological). 3. Drugs (General and Special). 
4. Balneology. 5. Local Therapeutical measures : — (i) Heat and Cold : 
(a) External and (b) Internal application, (ii) Medicinal agents : (a) 
to skin ; (b) to vulva ; (c) to vagina ; (d) to uterus. 6. Blood-letting. 
7. Operations, General measures : (i) Antiseptics ; (ii) Preparation of 
patient ; (iii) Ansesthesia — (a) Local, (6) General. 8. Therapeutical 
operations: (i) Dilatation of uterus; (ii) Curetting the uterus. 

I. General Hygiene. — Dr. Robert Barnes' dictum remains true, 
^^ Occupation, physical and mental, is the great panacea; something to 
do is the great female cry." 

There are two conditions of life which tend to aggravate, if not 
actually to produce pelvic disorders. The first is luxury, which allows 
a woman to spend her existence in indolence and ease, leaving her mind 
a prey to morbid introspection, and her body prone to functional debili- 
ties, which tend in the one case to hysteria, in the other to neurasthenia. 
These, especially the latter, are much more frequently observed in the 
wealthier classes. The second condition of life which aggravates pelvic 
troubles is continuous over-exertion ; this is chiefly found in women of 
the poorer classes, who have not the opportunities of adequate rest, or 
the change of environment after illness and parturition, which their 
richer sisters can ensure. 

The mode of living ought then to be between these two extremes of 
indolence and over-exertion. The mind should be free from anxiety 
and strain, yet at the same time actively occupied with some healthy 
intellectual pursuit, which should prevent mental stagnation ; the body 
should be stimulated by exercise suited to age, tastes, and circumstances ; 
and, above all, the importance of functional regularity should be insisted 
upon. 

The human functions of menstruation and gestation are instances of 
rhythm in the movements of nature; the intermissions of the hollow 
viscera occur in cycles, which are approximately rhythmical; the more 
regular the Avoman in these functional observances — in defsecation, 
micturition, the toilet of the skin, and exercise both mental and physi- 
cal — the healthier she will be ; and regularity of meals and sleep, both 
as regards time and duration, are no less important. 

A daily cold bath or cold sponging heightens arterial tone, strengthens 



G YN^ COL GICAL T HER APE UTICS 



251 



the heart's action, increases the corpuscular richness of the blood, and 
the haemoglobin richness of the corpuscles, and is at the same time 
a powerful nerve stimulant. Occasional hot baths, as means of more 
perfect cleansing, are also essential, and should either be taken just 
before bed ; or, if at other times, should be followed by cold sponging 
and rough towelling. The daily routine, especially as to baths and 
exercise, may need some modification during the menstrual period or in 
pregnancy. 

The women of all centuries are affected, more or less, for evil or for 
good, by the fashions of their generation. Clothes should be light and, 
as regards underclothing, loose in texture ; made either of silk or, far 
better, of wool ; or, if these cannot be worn, of loosely woven cotton, 
such as " cellular clothing " or ^' flannelette." Clothes should not prevent 
the freedom of muscular and respiratory action, and should uniformly 
cover all parts, not leaving the genital organs to be the least protected, 
as in the usual arrangements of underclothing. 

Exercise should never be excessive, and should be very moderate dur- 
ing menstruation. There are certain forms of exercise, such as rowing, 
which are less suited to women than to men ; but even these are harm- 
less if taken carefully during menstruation. Skill in such exercises 
should be acquired in early life, so as to avoid heavy strains and falls. 
It should always be remembered that active exercise in moderation 
does far less harm than passive exercise ; for when actively engaged, 
all the muscles of the body are at " attention," not " off guard " and 
relaxed. Thus riding and driving are often better than being driven, 
and bicycling is better than the pedal sewing machine, in which the leg 
muscles only are engaged. In cycling it is most important that the 
saddle should be wide enough to reach beyond the ischial tuberosities, 
which are wider apart in some persons than in others ; otherwise the 
perineum gets superficially hard and rigid, and the pelvic contents are 
unduly affected. Pneumatic broad or double saddles, with a very 
slightly elevated peak, are therefore the best. 

There are other forms of beneficial exercise, such as dancing, which 
are harmful only when indulged to excess, or in rooms where the air is 
rendered impure by overcrowding, or by gas. Football and gymnastics, 
unless of the parlour variety, are quite unsuited to adult women. 

2. Rest. — General ; Local; Physiological. 

In no department of medicine is " rest " more essential, whether in 
prophylaxis or treatment, than in gynaecology. In the pelvis as else- 
where, pain and disordered function are indications for rest. 

Pelvic rest may be obtained in two ways : by the complete quiescence 
of the individual, or by a local quietude. The former is a method which 
the leisured class can usually adopt, but is one of which the poorer 
classes, unless in a hospital or " home," are unable to avail themselves. 
For this reason some surgeons have considered it right to treat hos- 
pital patients more radically than private ones, and would, for exam- 
ple, remove the uterine appendages for certain varieties of tubo-ovarian 



252 SYSTEM OF GYNECOLOGY 

disease in a woman whose livelihood depends upon her activity ; 
whereas a lady with leisure and means might undergo a prolonged 
course of rest and palliative treatment, with a view, if possible, to avoid 
that operation. As a routine practice this is wrong, though in individ- 
ual cases it sometimes seems unavoidable. Each case must be judged 
solely by its own needs, and independently of the social or domestic 
engagements and desires of the patient, which often seem to her more 
important than medical advice. 

Local rest, so useful in cases of uterine displacements with congestion, 
may sometimes be obtained by means of the various forms of pessary, 
which may permit the patient to take active exercise, whilst the pelvic 
congestion, or the relaxed state of the uterine supports, are being simul- 
taneously improved by constitutional or other local measures. Such 
" local " rest is particularly useful where the patient belongs to the 
working classes and cannot obtain ''general " rest. 

Whatever mechanical means be used, general or local, physiological 
rest can only be obtained by total abstinence from coitus 5 and unless the 
husband will co-operate in this respect, all our efforts may prove fruit- 
less. Sometimes, however, it is either unnecessary or undesirable to 
enjoin sexual continence. 

3. Drugs. — A wide and precise knowledge of the action and uses 
of drugs is essential in the treatment of disease, whether of one set of 
organs or another. This is especially true in gynaecology, where, as 
already indicated, so much depends upon the functional and organic 
integrity of the rest of the individual. By the stimulation of extra- 
pelvic secretory organs great relief can be afforded to the intra-pelvic 
viscera. A few words, then, may be devoted to the principles which 
should guide us in the administration of the more general drugs. 

Purgatives. — In no class of diseases are purgatives more useful. 
Constipation, acting locally by the collection of scybala, may seriously 
displace the pelvic viscera; or, by exerting pressure on the venous 
plexuses round the uterus and in the broad ligaments, may cause much 
congestion and discomfort ; or, again, acting constitutionally, may dis- 
pose to systemic and portal congestion, which injuriously affect the pel- 
vic organs. In many cases of chronic pelvic disease a course of purgatives, 
such as sulphate of magnesium, cascara, or aloes, with a few doses of 
calomel, as occasion may require, will greatly relieve the patient. 

In certain obscure cases of pseudo-ileus (Olshausen) Malcolm, Tait, 
Treves, and Lockwood have shown that a speedy evacuation of the 
bowel may prevent a life being lost from that form of blood-poisoning, 
which is caused by the invasion of the system by bowel bacilli (bac- 
terium coli commune), which, though always present and usually 
harmless, may become extremely active and virulent in disease, or even 
on such bruising or over-stimulation of the intestines as may result from 
an undue manipulation of the bowel during an abdominal section. 

In many cases of acute pelvic inflammation it is far better to keep the 
bowels open daily by means of a simple mixture of cascara and sulphate 



GYNECOLOGICAL THERAPEUTICS 253 

of magnesium, than to keep the patient under the influence of opiates ; 
it is certainly better to do this than to alternate the use of opiates with 
strong forcing purgatives every two or three days. 

In suckling women purgatives are apt to affect the child. Castor 
oil and calomel seem, however, to be exceptions to this rule. Enemata 
and rectal injections of glycerine are useful alternatives. 

Tonics of all kinds may find a place in the treatment of pelvic 
disorders. 

Without going so far as Goodell, who says " one cardinal rule in 
the treatment of all uterine disorders is the internal administration of 
iron, and of other tonics, unless contra-indicated," there can be no doubt 
that iron is well borne in nearly all such cases. Iron should be given 
almost always with purgatives, otherwise it is often inert ; and in such 
cases as anaemia and chlorosis, with scanty or absent catamenia, it should 
also be combined (Barnes), with arsenic and freshly prepared acetate of 
ammonia. The perchloride of iron is very useful in cases of a septic 
nature, as in sapraemia and septicaemia ; and even in such cases as peri- 
uterine inflammations, where the ''septic" element is not so obvious. 
Iron is sometimes ill borne incases of hypertrophic endometritis, unless 
the vascularity of the uterus be simultaneously lessened by ergot. 

Permanganate of potassium, in doses of three grains (best combined 
with unguentum kaolin in the form of a pill), is very useful to increase 
the effect of iron ; in cases of anaemia with amenorrhoea it should be 
given thrice daily for three days, upon the date when menstruation 
should appear. 

Arsenic is valuable especially when leucorrhoea is present in anaemic 
girls, with a chronic catarrh of vagina or cervix; in them local treatment 
is not advisable until a fair trial of constitutional treatment has first 
been made. 

Quinine, which has a special tonic action on the uterine muscle, is a 
useful adjunct ; and in cases of debility or irritability of the involuntary 
muscles of the body it is usefully combined with strychnine, arsenic, 
and some sedative, such as belladonna, stramonium, or conium. 

Sedatives must be given with great caution. States for which they 
may be indicated are often recurrent; and the repeated administration 
of alcohol, opiates, etc., to women whose nervous system is overwrought 
or not under due control, especially at the climacteric, leads to continued 
use, or rather abuse of these agents. All such drugs should be given 
sparingly, and, if possible, so disguised or given in guarded prescrip- 
tions, that patients may not readily obtain a continuous supply. 

Special Gyncecological Drugs. — There are very few drugs for internal 
administration which are especially valuable for gynaecological purposes, 
and all of them are used for othor purposes also. 

The most important of these are ergot ; cannabis indica ; viburnum 
prunif olium ; hydrastis ; chloride of ammonium ; the bromides ; a few 
coal tar derivatives, such as phenacetin ; chloride of calcium ; mercurial 
preparations, and some others, such as castor and apiol. 



254 SYSTEM OF GYNECOLOGY 

Ergot of rye is used for two main purposes — to encourage uterine 
contraction and to lessen uterine haemorrhage. Its main action is on in- 
voluntary muscle fibres, causing a more prolonged and more definitely 
intermittent contraction, and, according to some observers, leading to a 
true tonic contraction if given in sufficiently continuous or large doses. 
Thus it is said to act upon the heart ; it causes also contraction of the 
arteries, and heightens arterial pressure. It may also cause some intes- 
tinal or vesical irritation, and may have to be given with belladonna to 
prevent such unpleasant sequences. Owing to its special action on the 
uterine muscle it is largely employed for the treatment of passive ute- 
rine haemorrhage, or for that due to organic changes, as in uterine fibroids 
or fungous endometritis, where diminished vascularity tends to lessen 
growth. It is also given to promote indirectly the absorption of effete 
products, and at the same time to reduce uterine congestion, by encourag- 
ing contraction ; it may thus lessen the bulk of the uterus in cases of sub- 
involution, and in cases of fibroids it may both starve the tumours and 
favour their extrusion. Ergot is apt to increase the pain of spasmodic 
dysmenorrhoea, and may therefore have to be omitted just before and at 
the commencement of a menstrual period : with this occasional interrup- 
tion ergot may be given continuously for months, or even for years, with- 
out deranging the health. Every now and then, however, large doses will, 
by contraction of the arterioles, give the heart more to do than it is equal 
to, and it may have to be discontinued. Ergot should be avoided during 
pregnancy, except in doses of 5 or 10 drops in certain cases of haemor- 
rhage (usually grumous), where we find on examination that the uterus 
has lost its normal firmness, its definite outline, and its intermittent con- 
tractions. Ergot should not be given during lactation, as it speedily 
enters the milk and produces infantile colic. Ergot, though usually 
given by the mouth in the form of the liquid extract, or as ergotin, may, 
in either of these forms, be subcutaneously injected, — the former deep 
into a gluteal muscle, the latter hypodermically, — and though somewhat 
apt to irritate, can usually be tolerated. Ergotinine, in doses of -g-g-o*^ 
to -Vth of a grain, is also useful hypodermically, but though less irritat- 
ing, it is less efficacious, and is also costly. In chronic haemorrhages, or 
where given for long periods, ergot should be combined with acids and 
purgatives ; but when given in severe acute haemorrhage it should be 
combined with ammonia. 

Hydrastis canadensis. — The best preparations are the tincture (dose 
TT^xx. to n\^lx.) and hydrastine (gr. \ to gr. 1). Though occasionally dis- 
appointing, this drug has a decided ecbolic action, and if taken regularly 
will check chronic haemorrhages not due to serious organic changes. 
The drug has also a sedative effect which ergot has not. 

Cannabis indica is usually given in the form of the extract (i to \ gr.) 
or of tannate of cannabin (gr. ij. to gr. x.). It is extremely useful in cases 
of menorrhagia with pain, acting even l3etter than hydrastis ; where the 
pain of dysmenorrhoea is present, as in some cases of fibroids, it acts 
far better than ergot, even when belladonna is added to the latter. 



GYNECOLOGICAL THERAPEUTICS 255 

Indian hemp varies greatly in strength, and should be ordered from one 
source ; it must be remembered that it is one of those drugs which are 
apt to affect certain women peculiarly, and at first must be given cau- 
tiously in small doses. Vertigo is a frequent symptom of an overdose. 

Viburnum prunifolium is an antispasmodic, relieving painful con- 
traction and cramps both of voluntary and involuntary muscle ; it is 
useful, therefore, to prevent abortion in cases where uterine contraction 
precedes the death of the foetus (extract, dose gr. ij. to gr. x.). 

A large group of antispasmodics and sedatives may be used in the 
treatment of uterine colic, but it will suffice here to name the good effect 
which phenacetin, antipyrin, exalgine, and other coal tar derivatives, as 
well as apiol and castor, have in the relief of all sorts of pelvic pain, 
including the pain of dysmenorrhcea, cancer, and neuralgia. Nitro- 
glycerine (gr. y-g-o^th) also relieves pain, and is especially useful in the 
last stages of cancer of the uterus, where ursemic symptoms, such as 
headache, scanty urine, and nausea, may have supervened. 

The bromides of potassium and ammonium allay the pain and general 
restlessness due to increased local tension, as for instance in cases where 
congestion of the ovary, or rapid growth of a fibroid, causes a painful 
distension of their enveloping capsules. They also tend to lessen 
haemorrhage of a passive type, and are particularly useful when taken 
so as to anticipate menstruation where menorrhagia is associated with 
antemenstrual dysmenorrhcea, headache, and nausea. 

Chloride of ammonium has also good effect in relieving pelvic con- 
gestion, probably by its action on the liver, and is therefore useful in all 
cases where the vascularity of the pelvis is increased, as in fibroids, 
subinvolution, chronic metritis, and simple congestion. 

Chloride of calcium, in doses of 10 to 20 grains thrice daily for two 
or three days, answers like a charm in some cases of menorrhagia, where 
ergot has failed, though the appropriate class of cases is not yet ascer- 
tained. It acts (13) by encouraging the ready coagulation of the blood. 

Perchloride of mercury, and other preparations of that metal, have 
some special use in promoting absorption of long-standing inflammatory 
exudations, such as are found in the chronic metritis of subinvolution, or 
as persistent thickenings about the pelvic floor, after pelvic inflammation. 

4. Balneo-therapeutics. — Such a large subject as this can only be 
very briefly outlined, but the following remarks and table will not be 
out of place : — 

There are certain health resorts and spas, at home and abroad, noted 
for springs of water which have been found useful in pelvic disorders. 
Some of the best are here tabled, but it must be remembered that it is 
often necessary to send a patient to a resort where the water is suitable 
rather to the constitutional diathesis than to the actual pelvic condition 
which may be a complication. Thus ansemic patients may be sent to 
Schwalbach, Nauheim, Levico, or Strathpeffer ; and gouty persons to 
Wiesbaden, Homburg, Bath, Harrogate, Kissingen, and many others. 

Sea-water, again, is a very good substitute where it is not possible to 



256 



SYSTEM OF GYNECOLOGY 



go to one of the following or other suitable resorts. Sea-water, when 
pure, is somewhat similar to Woodhall Spa water ; it is rich in salines, 
bromine, and iodine, is a powerful hepatic stimulant and purgative, and 
can be used internally as well as in the form of baths and douches, in 
some cases of portal and pelvic congestion, with great advantage. 

The following are some of the baths which are especially useful in 
cases of chronic pelvic congestion, subinvolution, or fibroids, and serve 
to hasten complete recovery after acute inflammatory attacks, where 
exudation into the uterine or periuterine tissues has been well marked. 

[For a more ample account of Balneology the reader is referred to the 
article by Dr. Weber in 8yst. of Med. vol. i.] 

Table of Baths and Health Eesorts for Chronic Pelvic 

Disorders 



Names of Places and Altitude. 


Season. 


Character of Water. 


Special Uses. 


Bex, Switzerland, 1400 ft. 


May to Sept. 


Saline water, bromo- 


Chronic pelvic exuda- 






iodurated 


tions. Fibroids. 


Carlsbad, Bohemia, 1214 


May to Oct. 


Alkaline saline. 120° 


Chronic pelvic con- 


ft. 




F. to 170° F. 


gestions. Gout. 


Contrexeville, France, 


June to Sept. 


Alkaline effervescing. 


Where gravel or uri- 


1000 ft. 




55° F. 


nary diseases com- 
plicate pelvic dis- 
orders. 


Franzenbad, Bohemia, 


May to Sept. 


Alkaline effervescing 


Pelvic congestion 


1900 ft. 




and ferruginous 


with haemorrhoids. 


Kissingen, Bavaria, 600 


June to Sept. 


Cold saline 


Pelvic congestion 


ft. 






with constipation. 


Kreuznach, Germany, 


May to Oct. 


Bromo-iodurated and 


Subinvolution. Chr. 


350 ft. 




saline 


inflammation. Fi- 
broids. 


Marienbad, Austria-Hun- 


May to Sept. 


Ferruginous mud- 


Chronic exudations 


gary, 910 ft. 




baths 


in cellular and 
peritoneal tissue. 


Plombieres, France, 1330 


June to Sept. 


Ferruginous. 66° F. 


Chron. endometritis 


ft. 




to 143° F. 


with ansemia. 


Pyrmont, Germany, 440 


May to Sept. 


Effervescing, ferru- 


Chron. catarrh with 


ft. 




ginous, and saline 


ansemia. 


Royat, France, 1480 ft. . 


June to Sept. 


Alkaline, ferruginous, 


Pelvic congestion 






and arsenical. 45° 


with gout. 






F. to 95° F. 




Schwalbach, Germany, 


May to Oct. 


Ferruginous 


Anaemia with chro- 


955 ft. 






nic catarrh. 


Salzbrunn, Bavaria, 2800 

ft. 
Vittel, France, 1000 ft. . 


May to Oct. 


Iodine springs . 


Chronic congestion. 


June to Sept. 


Alkaline effervescing 


Congestion with ob- 








stinate constipa- 








tion. 


Woodhall, Lincoln, 


May to Oct. 


Saline bromo-iodur- 


Subinvolution. Chro- 






ated 


nic inflammation. 
Fibroids. 



5. Local Therapeutical Measures. — i. Heat and Gold. — (a) External 
Applications. — Cold will excite reflex local contractions in both voluntary 



GYNECOLOGICAL THERAPEUTICS 257 

and involuntary muscle. In vigorous persons it increases the exhalation 
of carbonic acid. The effect of cold externally and suddenly applied is 
Avell seen when it is applied to the abdomen to cause uterine contraction 
in post-partum haemorrhage ; or to the skin of the new-born child to excite 
diaphragmatic movement. The reflex effect of cold upon distant glandular 
organs is less well understood ; but we know that cold locally applied 
temporarily checks secretion in all the glands — a check to be followed, 
in health, by a reactionary period of augmented secretion. 

Heat, if moderate, is sedative ; but if great, may excite muscular con- 
traction as does extreme cold, producing this effect with less shock to the 
individual. Hot baths are mainly sedative, relaxing the skin and its 
glands, dilating peripheral vessels, and thus relieving congestions of 
internal viscera : they are useful, therefore, in congestive dysmenorrhoea, 
prolapsed ovary, and the like ; and are very soothing to the flushings, 
the restlessness, and the irritability of the menopause. They also relieve 
muscular spasm and severe tension, and are therefore found serviceable 
in spasmodic dysmenorrhoea, and in cases of uterine, tubal, intestinal, 
hepatic, and renal colic. 

Hot foot and sitz baths act somewhat similarly. In the bath, blood 
is drawn from the internal organs to the surface and to the legs ; these 
baths are therefore useful in relieving pelvic congestion, and in cases 
where the catamenia have been suddenly arrested by " a chill " with result- 
ing stagnation of the pelvic circulation. After the bath the blood re- 
turns more freely to the pelvis, the circulation of which is re-established ; 
and the menstrual flow is thus encouraged to continue. Mustard added 
to such baths increases these effects. 

Poultices and fomentations, as regards both their utility and action, 
may be considered as local baths. If a sedative eifect be required, bella- 
donna or opium may be added to the fomentations ; if a stimulating 
effect, turpentine may be added. 

Poultices should be continuous, and should be repeated every three 
hours, or oftener if need be. If made thick and covered with oiled silk 
and flannel, and applied in the first instance 
very hot, they may remain somewhat longer 
at a suitable heat. If the local relaxation 
produced by a poultice be not wanted, a pad 
about a foot square can be made by sewing 
up some bran in quilted flannel. This can 
be put into the oven and applied dry, 
or may be kept hot by a Leiter's coil. 
By dipping this bran pad in ver}?- hot 
water it becomes a very light and ready 
poultice. 

Leiter's pliable metal coils (Fig. 52) have now taken the place formerly 
occupied by Chapman's spinal bags. Chapman showed that the heat or cold 
of these bags acted upon the spinal and ganglionic nerves going to the ves- 
sels. Thus ice-bags applied to the lower dorsal and lumber regions in ar- 

s 




258 



SYSTEM OF GYNECOLOGY 



rested menstruation, by partially paralysing these vaso-motor nerves, and so 
causing dilatation of the pelvic vessels, encourage a freer pelvic circulation. 




Fig. 53. — Application of Loiter's coils. 




Fig. 54. — Batli speculum. 

Hot applications to the same regions are, by analogous action, very use- 
ful in checking menorrhagia. Leiter's coils fulfil these objects admirably ; 
and the water can be regulated and kept at any given temperature either 



G YN^COL O GICAL THERAPE UTICS 



259 



by the addition of ice to the reservoir of T^^ater, or by a spirit lamp under 
it; and cooling can be increased or lessened by the rate at which the 
continuous stream of water is allowed 
to pass through the tubules of the coil. 
The pliability of the coil allows it to 
be moulded to any part of the body, 
and if the tubes be made of alumin- 
ium their weight is trifling. 

For reducing temperature, a coil can 
be moulded to the back of the head, 
and iced water allowed to run through 
it. For rallying a patient suffering 
from shock, heated coils applied to the 
feet, on the chest, and under the arms 
answer admirably. If moist heat be 
required to imitate a poultice, cloths 
wrung out of warm water can be wrapped 
round the hot coil. 

(&) Internal Apijlications of Heat and 
Cold. — Whilst in a bath, water can be 
made to enter the vagina by means of a 
grilled speculum (Fig. 54). The more 
usual means, however, is a douche 
apparatus. In all cases the flow into 
the vagina should be continuous — from 
an elevated supply of water, as from a 
suspended douche-can, or from an ele- 
vated syphon arrangement (Fig. 60) ; 
not intermittent, as when a hand-ball 
enema is used. If a douche-can be 
the vessel employed, the outlet should 
be slightly above the level of its base, 
lest imperfectly mixed powders, or other 
ingredients, should escape in too con- 
centrated a form. 

If cleansing alone be needed, two 
or three pints of water are sufficient; 
but for relief of local congestion irri- fig. 55.- Syphon douche. 

gation is employed, and several pints are used for twenty to thirty 
minutes. The value of this procedure, however, is probably over- 
estimated. 

The vaginal nozzle should be of toughened glass, and capable of being 
easily cleaned. The patient should lie flat on her back, with the pelvis 
raised on a bed-bath (Fig. ^Q>), or projecting over the edge of a couch. 

For the mere application of heat, all that is necessary beyond these 
■|:>oints is that the temperature of the water should be properly regulated. 
In prolonged douching for relief of congestion, lukewarm water (95° F. to 




26o 



SYSTEM OF GYNECOLOGY 



105° F.) is indicated ; but for arrest of hsemorrhage, or the production of 
muscular or vascular contraction, a temperature of 118° F. is required. 
Extremely cold water will also check haemorrhage, though it will not pro- 
mote coagulation of the blood ; it is, however, obviously unsafe to em- 
ploy it, as it may unduly check secretion, or prevent the menstrual flow 
from appearing if due. It is also much more trying to the general 
health of the patient, and water at so low a temperature is not readily 
obtainable. 

It must be remembered, however, that, in addition to the thermal 
properties of the vaginal douche, it also has a very well-marked mechanical 
action. This is best obtained by so elevating the douche-can as to make 
the continuous current of water somewhat forcible, and capable of bal- 
looning the vagina. This action raises the uterus with its appendages 




Bed-bath. 



and the other pelvic contents, empties engorged lymphatic vessels, glands, 
:and distended veins, and gently stretches, and perhaps promotes the 
absorption of chronic inflammatory thickenings. 

This ballooning of the vagina can be increased by further elevation of 
the reservoir, or by the patient arresting the outflow of the water from 
the vagina by hand pressure on the vulvar orifice. 

By the addition of medicinal agents the douche can be rendered 
antiseptic, anodyne, astringent, or sedative. These further actions will 
be discussed later (p. 261). 

(ii) Medicinal agents applied to (a) the skin ; (b) the vulva ; (c) the 
vagina ; (d) the uterus. 

(a) TJie Skin. — Counter-irritation to the skin may be applied in 
a variety of ways, by such drugs as cantharides, mustard, turpentine, 
iodine liniment, croton oil, and others in ordinary use. 

They all lessen pain and appear to check the spread of inflammation, 
and also to promote absorption of inflammatory exudations. These 
results are probably brought about by influencing the vaso-motor nerves ; 
but, by stimulating the skin, they lead also to its increased vascularity, 



GYNAECOLOGICAL THERAPEUTICS 261 

and presumably to a relatively diminislied vascularity of subjacent tissues. 
It is clear too that there is some distinct action upon the terminations of 
the nerve filaments from the spinal cord ; and for this reason counter- 
irritants should be applied over the position where the nerve trunks, 
which supply the inflamed organs, send branches also to the surface of the 
skin. These areas, as Dr. Head has shown, are not necessarily at the site 
of greatest pain, but where the touch of a blunt point like a pin's head 
detects hypersesthesia. It is found that these areas are supplied by the 
posterior root of the same nerve which also sends sensory nerves to the 
inflamed viscera. Thus the ovary, when inflamed, causes referred pain 
and cutaneous tenderness along the tenth dorsal area ; the nerves going 
to inflamed Fallopian tubes are particularly associated with the eleventh 
and twelfth dorsal segments ; so also are the nerves supplying the upper 
parts of the cervical canal and the internal os : the lower part of the 
cervix is related to the third and fourth sacral areas. Much valuable 
information on this subject may be found in Dr. Head's paper. 

It is difficult, of course, to estimate the curative eft'ect of counter- 
irritants, in those cases where rest in bed is a coincident factor in the treat- 
ment, and wherever possible these two means should be associated. 

(5) Applications to the Vulva. — The various inflammatory and other 
morbid states of the vulva are dealt with as are other places in the body, 
which resemble it in being covered partly by skin, partly by mucous 
membrane, with a good deal of transitional epithelium at the points of 
union. Ointments, lotions, fomentations, and baths have each their 
appropriate usefulness. If the vulva alone be affected, especially in young 
children, baths form the best means for applying sedative or stimulating 
lotions. 

(c) Applications to the Vagina. — Medicaments may be applied to the 
vagina in many ways. Among them may be mentioned injections, 
douches, tampons of prepared wool or gauze, pessaries made up with cacao 
butter or gelatine; or applications, in the form of ointment, powder, or 
solution, may be made to definite areas of the vagina through a grilled 
or duckbill speculum. 

Douches are a very convenient way of applying medicaments to the 
vagina where only temporary influence is required. If used for antiseptic 
purposes, perchloride of mercury may be used in the proportion of 1 to 
4000 or 2000 ; or if prolonged use be needed, carbolic acid (1 in 100), 
or tincture of iodine (3j. to pint), or borax or boric acid or izal may be 
substituted in the same proportion. Condy's fluid and sulphocarbolate of 
zinc are also useful, and creolin, or lysol (1 in 200) is more suitable before 
a vaginal operation when it is important that the vagina should be soft 
and supple ; most of the other antiseptics render it temporarily unyielding 
and contracted. For rendering the vagina absolutely antiseptic more 
complete measures may be needed (see p. 270). Douches can be made 
sedative by means of the addition of liq. plumbi subacetatis (3ij. to 
Oiij.), laudanum, or liq. opii sedativus (3j. to Oj.), chloral hydrate (gr. 
XX. to Oj.), borax or bicarbonate of soda (3ij. to Oiij.), or Condy's 



262 SYSTEM OF GYNECOLOGY 

fluid well diluted. Of astringent preparations, alum, sulphate of zinc, and 
tannin (in the proportion of half a drachm to the pint) are the best. 

Medicated pessaries can be used for all purposes. Absorption is slow 
and imperfect through the vaginal mucous membrane, and at least double 
the usual dose of a drug should be thus administered. Only those drugs 
are thus used which are known to have a local effect. They are best com- 
bined with gelatine or with cacao butter, the latter being itself very 
soothing. The drugs most often used as sedatives are cocaoine (gr. ij.), 
morphia (gr. j.), extract of belladonna (gr. ij.), henbane extract (gr. v.), 
hemlock extract (gr. v.). Astringent pessaries should be made up with 
cacao butter; alum and tannin are the agents most used. 

If we desire to relieve vaginal congestion, or to encourage secretion 
from the vagina, a pessary of glycerine (3iss.) combined with gelatine (3ss.) 
is very efficacious. This agent has one of its most useful applications as 
a preliminary to rapid dilatation of the cervix, the nurse being directed to 
introduce the pessary up to the level of the cervix two hours before 
the operation. If desired, drugs may be added to these pessaries to 
make them antiseptic or sedative ; and it is in this form that ichthyol, 
^iij. in each pessary, has its most useful sedative and absorbent applica- 
tion. Ichthyol pessaries are also very beneficial in subinvolution asso- 
ciated with endocervicitis and granular erosion. 

Tampons may be employed to plug the vagina, or lightly to pack it ; 
but they are sometimes used as a convenient method of applying 
medicinal preparations to the walls of that passage. For this purpose 
gauze is easily applied saturated with various ingredients, such as carbolic 
acid, eucalyptus, iodoform, sal alembroth, salicylic acid, sanitas, or thymol ; 
or plain gauze previously dipped in the desired drug, such, for instance, as 
a 4 per cent solution of ichthyol and glycerine, may be used. Wool like- 
wise, tied into convenient sizes, may be used, and can be obtained saturated 
with boracic acid or iodoform, or containing perchloride of mercury, 
eucalyptus, iodine, carbolic acid, or salicylic acid. Wool tampons can be 
made with astringents, such as alum or tannin, either mixed throughout 
the wool or rolled up inside it. Wool tampons steeped in glycerine may 
be used instead of glycerine pessaries, and are very beneficial where the 
uterus needs support and depletion at the same time. 

If it be desired to elevate the uterus, to keep the cervix forwards or 
backwards, or merely to rest the uterus after some operation in which it 
has been much drawn out of position, or in which adhesions to other 
viscera have been broken down, there is no need to pack the vagina very 
tightly ; but this is very desirable where there is severe uterine 
hsemorrhage, though it is better to plug the uterine cavity itself, a 
much more certain haemostatic procedure. 

If the vagina is to be packed for hsemorrhage it should be rendered 
absolutely antiseptic, and the rectum and bladder should be emptied. The 
patient should lie in the Sims' position, and a duckbill speculum should be 
passed. A piece of gauze should be inserted into the cervical canal, and 
the pouches around the cervix should be firmly packed with antiseptic 



G YNy^ COL O GICAL THERAPE UTICS 



263 



gauze ; a piece should also be laid over the cervix. Pieces of wool rolled 
up into cylinders about as large as the first thumb joint should be then 
passed up and pressed firmly against this roof of gauze, and the vagina 
completely filled ; the strings attached to the wool tampons should be 
allowed to hang out of the vagina. As a rule they should be left in for 
twenty-four hours, and it will generally be found that the haemorrhage 
has been arrested by coagula in the upper gauze layers. 

Ointments containing useful drugs may be conveyed into the vagina 
by ointment carriers, such as Allingham's or Matthews Duncan's (Fig. 57). 




Fig, 57. — Ointment carrier (^Matthe\v3 Duncan's). 

The basis of such ointments should be lanolinated lard. 

Direct applications of drugs can be made through a speculum to any 
affected area of the vagina, and in variety they cover a wide range. 
Nitrate of silver up to a strength of gr. x. to 3j., or an 8 per cent solution 
of sulphate of copper, is useful 
in some inflammatory states ; pure 
carbolic acid, chromic acid, acid 
nitrate of mercury, bromine dis- 
solved in spirits of wine (1 in 
4) are all useful, with appropri- 
ate precautions, in cases of new 
growth or malignant ulceration. 

(d) Applications to the Uterus. — 
Medicaments used for the vagina 
may also be employed for the 
vaginal portion, but more care is 
required for intra-uterine appli- 
cations. 

To apply substances to the 
endocervix it must be exposed in 
a speculum, such as Neugebauer's 
(Fig. 58), in a good light; after its 
lining membrane is wiped free 
from mucus, the solution or pow- 
der should be applied on a probe, 
such as Playf air's, armed with cot- 

, T rm 1 , , Fig. 58. — Diverging speculum (Neugebaur's). 

ton wool. The substances most 

used are acidum carbolicum liquef actum, iodised phenol,^ iodine liniment, 

iodine paint - or Churchill's solution of iodine,^liquor f erri perchloridi, and 

1 Iodine 1 part, and liquid carbolic acid 4 parts. 

2 Iodine, iodide of potassium, spirits of wine, and water, equal parts (Samaritan 
Free Hospital). 

3 Iodine, 78 grains ; iodide of potassium, 90 grains ; rectified spirits to one ounce. 




264 SYSTEM OF GYNJECOLOGY 

ichthyol (4 to 10 per cent solution). Another good method is to pour 
down a Fergusson's speculum a solution which can be encouraged to 
enter the cervical canal freely by means of an armed probe. One of 



Fig. 59. — Playfair's probe. 

the best solutions for this purpose is an 8 per cent solution of sulphate 
of copper. 

If there be much congestion, the cervix should be first punctured 
till it has assumed a light pink colour. 

Where the endometrium is extensively inflamed, or is the seat of 
adenomatous overgrowth, dilatation and curetting become necessary ; but 
there are many milder inflammatory conditions of the endometrium, in 
which a cure can be obtained by several careful applications of one or other 
of these or other drugs to the cavity of the uterus. They are best used 
through a Fergusson's speculum, and should be carried into the uterus on 
a Playfair's probe ^ suitably curved. The cervix should be exposed and 
cleansed, and a sound passed to ascertain the exact uterine curve. If this 
curve be acute, the cervix should be held and drawn down by a tenaculum 




Uterine tenaculum forceps (Sims'). 



(Fig. 60) ; and if the sound prove any constriction to exist, a few bougies 
should first be passed : indeed, in any case the application of a powerful 
medicament may usefully be preceded by a partial dilatation, as uterine 
colic is thereby prevented and good drainage facilitated. Except in rare 
cases these proceedings should be taken when the patient is in bed and 
able to be at rest for some hours. After the application, it is a good plan 
to pass into the uterus, above the level of the os internum, a thin strip 
of gauze or lint, soaked in iodine and glycerine, to ensure a watery dis- 
charge and free drainage. It should be removed in twelve hours, and 
an antiseptic douche given. When it is advisable to apply a medica- 
ment over the endometrium only, it may be done through a cervical 
speculum, such as Atthill's (Fig. 61). 

1 The best variety of Playfair's probe is that in Fig. 59. It has not a bulbous end, 
but tapers slightly, and the wool, though held sufficiently firmly not to come off when 
the probe is withdrawn, will come off readily enough afterwards without scissors. 



G YN^ COL GICAL THERAPE UTICS 



265 




Fig. 61. 



Intra-uterine canula (Atthill's) ; plathiuui 
canula, with stilette. 



Intra-uterine injections should never be used without security of free 
exit 5 and in any case no very irritating solution should be injected lest sud- 
den uterine contraction should 
occur. It must be remembered 
also that occasionally the Fal- 
lopian tubes remain patent as 
a result of disease, or as part of 
a general pelvic subinvolution. 

6. Blood-letting. — Some- 
times it is desirable to relieve 
congestion by the local abstrac- 
tion of blood. This may be 
done by applying leeches, by 
puncturing, scarifying, or dry 
cupping ; or the result may be arrived at by the extraction of blood- 
serum, as when blisters are applied, or when vaginal glycerine tampons 
are introduced. Whatever be the precise method adopted, it should 
either be carried out at the place actually con jested, such as the vulva 
or cervix uteri, or at a part supplied by blood-vessels, which are either 
branches of the same main trunk or anastomose freely with its off- 
shoots. 

Thus leeches applied to the perineum relieve pelvic congestion, by 
depleting the superior, median, and inferior heemorrhoidal vessels coming 
from the common iliac, internal iliac, and pudic arteries respectively ; 
between all of which there is free anastomosis. Relief is, of course, thus 
afforded to the portal as well as to the general system, as the superior 
hsemorrhoidal vein belongs to the portal, while the middle and inferior 
belong to the general venous system. Mr. Marmaduke Sheild has drawn 
attention to the relief afforded to vesical and pelvic congestion and irrita- 
tion by the applications of leeches or counter-irritation to the inside of 
the thighs. This he accounts for partly by vaso-motor influence, but 
mainly by the depletion of the capillaries fed by the pudic branches of 
the femoral, relieving thus the areas of congestion by lowering the blood 
pressure in the branches from the internal pudic of the internal iliac, 
with which they freely anastomose. 

Leeches to the groin can be shown to act in a similar manner, and 
the signal relief thus afforded to swollen ovaries is probably produced by 
depleting the small twigs from the ovarian artery which pass along the 
round ligament to the inguinal canal, as well as, more indirectly, through 
the anastomoses between the superficial and deep epigastric vessels and 
deep-lying twigs from branches of the internal iliac vessels. 

Leeches to the Cervix. — Blood may be abstracted from the cervix by the 
application of leeches, by puncturing, or scarification. Blood thus drawn 
relieves the whole pelvis. The cervix is mainly supplied from the uterine 
arteries ; but these anastomose so freely with the ovarian and vesical 
arteries that the relief becomes very general. The vagina should be 
douched with some warm antiseptic solution, such as borax (3ij. to Oiij.), 



266 SYSTEM OF GYNAECOLOGY 

the patient being in bed in a warm room. She should lie on her side 
whilst a Fergusson's speculum is passed, which should exactly embrace 
the cervix uteri. The cervix must then be carefully cleansed, and its 
cavity, especially in parous women, should be occluded by some antiseptic 
wool. If it be desired to apply the leeches to any particular spot on 
the vaginal portion, they can be passed down to the cervix in a hollow 
tube, or held lightly in a pair of forceps ; but as a rule it suffices to throw 
the leeches up the speculum, which is kept well pressed up against the 
fornices of the vagina. The leeches seize hold where they will, and a 
large wool tampon is then passed up nearly to the cervix and kept in 
for ten or fifteen minutes ; the wool is then removed, and the leeches, 
probably then detached, can be easily rolled out. The cervix may then 
be painted with iodine solution, or an antiseptic douche given. Cai-e 
should be taken that the leeches do not attach themselves to the vaginal 
wall, as serious haemorrhage may follow by perforation of a small vessel. 
If a leech-bite should thus bleed, pressure applied by means of a vaginal 
tampon, or the application of strong iodine or perchloride of iron, usually 
stops it ; but if these methods fail, a red hot wire, or the point of a 
Paquelin's cautery knife at a dull red heat, always succeeds. Where the 
parts are too tender for a vaginal plug this method should be at once 
employed. 

If it be desired to keep up a little oozing after leeching or punctur- 
ing, warm douches may be given, or a glycerine tampon introduced. 

Puncturing and Scarifying the Cervix Uteri. — Sometimes leeching the 
cervix appears to be of less permanent good than puncturing ; for although 
more blood is lost by the former method, say two drachms to each 
leech, there is more suction of blood to the part than where puncturing 
is employed. In cases of congestion of pathological origin, with marked 
blueness of the cervix, instantaneous relief is afforded by the abstraction, 
by puncture, even of two or three drachms — the cervix becoming and 
remaining pink : thus it becomes evident that the circulation, which was 
stagnant, is restored. Puncturing is done by exposing the cervix in a 
speculum, rendering the surface antiseptically clean, and then with a long- 
handled sharp-pointed knife (Fig. 62) gently stabbing the vaginal aspect 



'Ja BCAI.B 

Fig. 62. — Uterine scarifier. 

of the cervix. These stabs should be very slight at first, so as to 
indicate the tendency to bleed ; they may then be increased in depth 
and number till the loss is considered sufficient. Cross cuts (scarifying) 
may be employed instead of these punctures, or as an addition to them. 
The subsequent treatment is as for leech-bites. Such an abstraction of 
blood may be required once a week, for two or three times, the effect 
being continued by drugs, hot douches, and glycerine pessaries, with rest 
and diet according to circumstances. If much congestion be present in 



GYNECOLOGICAL THERAPEUTICS 267 

cases of endocervicitis, or endometritis, a preliminary puncturing is 
advisable before applying remedies to the lining membrane. 

7. Operations. — General Measures : (i) Antiseptics. — There is nothing 
peculiar to gynaecology in the rules of antisepsis, except that it is 
more difficult to ensure absolute asepsis in the vagina and endocervix 
on account of the folds and glands there found. The importance of 
antiseptic vaginal surgery cannot, however, be too strongly insisted upon, 
for it must be remembered that there is a direct communication between 
the vulva and the peritoneal cavity, with only partially protective 
anatomical barriers at the hymen, external and internal os uteri, and 
uterine cornua. The danger, therefore, of conveying infective or septic 
products by incautious handling from a lower to a higher level of the 
genital tract is very evident. Every one has heard of septic inflammation 
following the use of a sound — doubtless traumatism plus sepsis — and it 
is, of course, useless to cleanse the sound well if it be allowed to pass 
through a septic vagina en route to the uterus. The sound should there- 
fore either be passed along an antiseptically clean finger, and through an 
equally clean vagina, or it should be introduced through a speculum ; and, 
if there be any suspicion of taint, it is safer to pass afterwards a Playfair's 
probe armed with wool dipped in tincture of iodine or other antiseptic 
solution. No one nowadays would dream of dilating a uterus except 
under strict antiseptic precautions ; yet similar precautions are rarely 
thought necessary for the passage of the sound, where precisely identical 
risks are run. Indeed, the risk of passing a sound may be greater, 
because drainage may be very incomplete, and any infective material 
carried up is almost necessarily retained in the womb. Without anti- 
septics the most trifling operation on the generative organs may end in 
disaster ; with rigid antisepsis it seems possible to do almost anything 
with impunity. 

The subject of antiseptics may be subdivided as follows : — (a) Anti- 
sepsis as regards the operator and assistants, (b) Antisepsis as regards 
instruments and sponges, etc. (c) Antisepsis as regards ligatures, sutures, 
etc. (d) Antisepsis as regards the patient, (e) Her environment. 

(a) Antisepsis as regards the Operator and his Assistants. — The opera- 
tor's (and his assistants') arms should be bared to the elbow, and he should 
be covered with a clean mackintosh apron reaching from neck to ankles. 
The hands and arms should be thoroughly washed in two basins with 
soap and water, especial care being taken of the nails. The skin should 
then be rinsed with clean sterilised water, and dried by a previously 
sterilised towel. In most cases all that is further required is to steep 
the hands for two minutes in a 1 per 1000 solution of corrosive sublimate 
solution, and allow them to dry ; but if the operation be an abdominal 
one, further precautions are desirable. Thus the hands and arms may be 
steeped in a saturated (4 per cent) solution of permanganate of potash (the 
resulting stains may be removed in one minute by a 1 in 20 sulphurous 
acid solution or a saturated oxalic acid solution), and finally in the 
corrosive sublimate solution as above. Sanitas or turpentine, poured on 



268 



SYSTEM OF GYNECOLOGY 




Fig. 63. — Steriliser for instruments 
(Harrison Cripps). 



the hands after an operation, render them quite free from any offensive 

odour. Cold water removes blood from skin better than hot. 

(6) Antisepsis as regards Instruments, Sponges, etc. — Instruments 

should be placed in boiling water or steamed (Fig. 63) before as well as 

after the operation, and then laid in 
a tray, similarly prepared, containing 
hot carbolic solution, 1 in 40 to 1 in 
20. Both corrosive sublimate and 
iodine solution corrode steel and 
plated instruments, and Condy's fluid, 
lysol, and creolin solution obscure the 
transparency of the water. All in- 
struments should either be capable of 
being taken to pieces and thus easily 
cleaned, or should be made out of a 
single piece of metal, handles of wood 
or bone being avoided. During the op- 
eration all instruments should either 
be placed again in the tray of carbolic, 
or they may be laid upon a clean 

towel, and dipped in the carbolic solution before being again used. 

Extra care must be taken to clean the eyes of needles and the rough 

surfaces and joints of needle-holders, artery and other forceps, scissors, 

and the like. It is important that instruments used at an operation 

should not be allowed to dry before being cleaned. 

In most operations sponges maybe superseded by the use of antiseptic 

Avool carried on holders, or made into pads or pledgets. These pads are 

best made by having gauze sewn round them; they should then be 

rendered antiseptic by boiling for two hours, and kept in a solution of 

carbolic acid, 1 in 20, or in sublimate solution, 

1 in 1000. Before use they are wrung dry, 

and may be employed, after careful recleans- 

ing, throughout the operation. If sponges be 

used they should be prepared as follows : 

— Immediately after use they should be 

thoroughly cleansed till the water remains 

untinted, and then soaked for from two to 

four hours in four pints of warm water (for, 

say, 25 sponges), in which a handful of wash- 
ing soda has been dissolved. The sponges 

are then removed and well washed in three 

or four waters to remove sliminess, and finally 

soaked for twenty-four hours in a covered 




Fig. 04. — Glass jar for spongo. 
wool-pads, etc. 



bowl, containing a 1 in 500 sulphurous 

acid solution, which bleaches them. After 

being well dried they are wrapped in a sterilised towel, or put away in 

a large hermetically closed glass jar (Fig. 64), with a small quantity of 



G YN^ COLO GICAL THE RAPE U TICS 



269 



alcohol. For some hours before the operation they should be soaked in 
a 1 in 20 solution of carbolic acid, which should be diluted with equal 
parts of boiling water at the time of the operation. The nurse who 
has charge of the sponges should squeeze them thoroughly before handing 
them to the assistant operator, and during the operation they should be 
thoroughly rinsed in hot carbolic solution till free from all blood, etc., 
and then kept in the 1 in 40 carbolic solution till 
required for further use. 

(c) Antisepsis as regards Ligatures and Sut- 
ures. — Silk when used for ligatures may either 
be left long, as in vaginal hysterectomy, to come 
away in from five to twenty days; or may be cut 
short and so gradually destroyed by the action of 
leucocytes after a much longer period, — sixty- 
four days, according to Thomson of Dorpat. If 
in the peritoneum, they may require, according 
to Ballance and Edmunds, at least 500 days for 
their complete absorption- 

The best silk for internal ligation or suturing 
is China twist; though when it gets dry, as it 
would if used externally, it tends to kink and coil. 
Floss silk is more apt to slip when being knotted. 
Silk must be used sufficiently thick to be firmly 
tied, but must not be too thick to make a deep 
ligatured. It will also be noted that the thinner 
rapidly does it come away or get absorbed. 

In using silk ligatures be sure that they have been efficiently 
sterilised (Fig. 65), and that they remain antiseptic. As boiling per- 
ceptibly weakens silk, after being so treated its strength should be always 
tested before use. Previous to the operation the silk should be well 

soaked in a 1 per 1000 




. 65. — Steriliser for 
ligatures. 

groove in the part 
the silk the more 




G6. — Catgut or silk sterilised in alcohol. 



corrosive sublimate solu- 
tion, or in a 1 in 20 
carbolic acid solution. 
When not being used it 
may be wound on glass 
reels, and kept in air- 
tight glass bottles (Fig. 

Every operator has 
his own way of prepar- 
ing catgut and rendering 
it antiseptic. It seems 
best to soak it in ether 



(Pozzi) to remove any grease, and so allow antiseptics to enter freely 
among its fibres. Then it may be immersed for one hour in a 1 per 
1000 solution of corrosive sublimate, and afterwards rolled on glass plates 



270 SYSTEM OF GYNECOLOGY 

or cylinders, and steeped in oleum ligni juniperi for a week, to render 
it supple and flexible ; it should then be kept in a mixture of rectified 
spirit and juniper oil (10 per cent) in an air-tight bottle till wanted. 
Immediately before being used it should be immersed in the subli- 
mate solution. Catgut is usually absorbed in about ten days. 

Silkworm gut is the most imperishable organic ligature known. It 
is bought in bunches of 50 or 100 strands, the curly ends of which should 
be cut oft", and the straight intervening portions only used. These should 
be rendered antiseptic by boiling in a 1 in 20 carbolic acid solution, and 
should then be kept in long glass bottles, containing absolute alcohol, 
for preservation. Before being used they should be placed in boiling 
water to make them supple and pliable. 

Silver wire should be kept in a 1 in 20 carbolic acid solution, and 
before being used should be well polished by friction with wash-leather, 
then boiled, and replaced in the carbolic solution. 

Glass drainage tubes should be boiled in sublimate or carbolic acid 
solution, and india-rubber tubing may be similarly treated for not more 
than fifteen minutes, being subsequently kept rolled up in antiseptic 
gauze, or in stoppered bottles containing weak sublimate or carbolic 
solution. To preserve india-rubber tubing, oil of all sorts, iodine, and 
a temperature higher than 120° C. should be avoided. 

(d) Antisepsis as regards the Patient. — Although the patient is pre- 
pared for some days previous to the operation by baths, yet much re- 
mains to be done before the skin and other parts are really aseptic. 

a. Before Abdominal Section. — There is probably far more danger 
to the patient from infection from her own skin, sweat glands, and so 
forth, than from the germs which may and do enter from the atmos- 
phere. The glands open so freely on its surface that it is doubtful 
whether it be possible to purify the skin perfectly. The permanganate 
and oxalic acid method is one of the best methods for aiming at perfection. 

After freely washing the skin, and especially the umbilicus, with 
soap and water, and subsequently with ether, to remove any fatty 
material, the surfaces should be washed several times with strong per- 
manganate of potash solution, which stains the skin of a deep mahoganj^ 
•colour. This discoloration can be removed by a 1 in 20 sulphurous acid 
solution, by a concentrated oxalic acid solution, or to a less perfect ex- 
-tent by sanitas or turpentine. This should be done some hours before 
the operation, and the abdomen should then be covered by a wool or 
gauze pad wrung out of a 1 in 40 carbolic acid solution ; when this is 
removed immediately before the operation the skin should be carefully 
washed with a 1 in 1000 sublimate solution. 

y8. Before operations on the perineum or per vaginam, the nurse 
will douche the vagina twice daily for two or three days with hot 
water containing tincture of iodine (1 in 150), or carbolic acid (1 in 60), 
or corrosive sublimate (1 in 2000) ; and after carefully washing the 
external genitals and perineum, will foment them with the same sub- 
limate solution. If so directed, she will also shave the vulva and peri- 



G YN^COL GICAL THE RAPE UTICS 



271 



neum before the operation. Three hours before the operation the last 
toilet should be effected, by douching the vagina and washing the 
genitals either with sublimate, or as indicated for abdominal section ; 
and when so instructed she should clean the vagina more thoroughly by 
manipulation and swabbing, and pack it lightly with antiseptic gauze. 

At the operation the gauze should be removed, and the vagina 
vigorously douched and well swabbed out with cotton- wool pads satu- 
rated with 1 per 1000 sublimate solution ; the cervical cavity should be 
similarly treated. 

In some vaginal operations a continuous stream of antiseptic (carbolic 
or iodine) lotion may be kept running over the parts, either by using 
instruments hollowed out like a flushing curette, or by special arrange- 
ment. After the operation a douche should, as a rule, be given, antiseptic 
dry pads applied to the perineum, and possibly a vaginal antiseptic 
gauze tampon also employed. Subsequent contamination by urine and 
faeces must be prevented for some days by catheterisation and careful 
cleanliness. 

(e) The Surroundings of the Patient. — From the antiseptic point of 
view the room in which the operation is to be performed should be 
scrupulously clean ; and as a rule, whatever the nature of the operation, it 
is desirable to operate in a room apart from the ward in which the patient 
has previously been sleeping. After abdominal section the patient should , 
if possible, be in a room isolated from other wards for some days. 

The operation room should be well lighted by windows, and should 
also be provided with electric light. The walls of the room and the 
ceiling should be distempered, and its floor made of concrete or polished 
wood-blocks. For abdominal operations a room on the top floor, with 
a skylight, is very advantageous. The furniture should be scanty, and 
made of glass and enamelled iron, so as to be easily cleaned. 

If a case have shown any evidence of a septic process the ward must 
be thoroughly disinfected, before another case is admitted, by having the 
floor and furniture washed with sublimate lotion, by having sulphur 
burnt in the room with all its outlets closed, and by having its walls and 
ceilings freshly distempered. The bed-furniture should be sterilised, 
and the mattress should be destroyed. 

It is almost superfluous to add that the drainage of the house must 
be absolutely perfect, and that the water-supply, both hot and cold, must 
be pure and ample. 

(ii) Preparation of the Patient, apart from Antiseptics. — When it is 
known that a patient is to be operated upon in a few days, everything 
should be done to promote the functional activity of her organs so that 
she may better withstand the ordeal of the operation, and perhaps avoid 
a tedious convalescence. 

Her diet should be light and nutritious, with plenty of non-alcoholic 
fluid to encourage the skin and kidneys to act freely. Warm baths at 
bedtime, with free use of soft soap and a brisk towelling, should be 
ordered, and the bowels should be regulated by some such mild pill as 



272 SYSTEM OF GYNECOLOGY 

pil. coloc. CTim hyoscyam. gr. iv., pil. hydrarg. gr. j., at bedtime, followed 
by a seidlitz powder in the morning. On the morning of the operation 
the larger bowel should be emptied by an enema ; and if it be evident 
that the rectum will, after all, be active during the operation, it may be 
advisable to pass a suppository of pil. plumbi cum opio, gr. v., two hours 
beforehand. 

Before the operation a good night's sleep should, if necessary, be 
ensured by means of a harmless drug, such as 30 or 45 grains of 
bromide of ammonium. 

No solid food should be administered for at least eight hours before 
the operation, though some diluted milk, or ^%% and milk, or peptonised 
raw beef juice may be given three hours beforehand. 

Immediately before the operation the patient should either pass 
water, or have the catheter passed by the nurse. 

At the time of the operation the patient should be warmly but 
loosely clothed, the exact details varying necessarily with the nature of 
the operation. 

The bed into which the patient will be put after the operation should 
be warmed by a hot bottle, which should lie at the foot ; and an extra 
blanket should be provided till the skin acts freely. 

(iii) Ancesthesia, Local and General — (a) Local AncestJiesia. — Cocaine 
is the agent mostly used as a local anaesthetic, both for the relief of severe 
pain, pruritus, or other form of local hypersesthesia, and also prior to 
operation, where, for any reason, general anaesthesia is contra-indicated. 

Cocaine (10 to 20 per cent) may be painted on the skin or mucous 
membrane, or may be rubbed on as a lanolinated ointment ; after a few 
minutes the tissue loses all sense of contact, and becomes " w^ooden,'^ as 
the patient generally describes it. Minor operations, such as opening a 
superficial abscess, or cutting or burning off a wart or a mole, can then be 
painlessly performed ; but if the operation involve deeper incisions, co- 
caine should be injected hypodermically, or better still, both endermically 
and hypodermically. To do this, three or four drops of a 2 or even a 1 per 
cent solution should be used for injection in several places, at distances 
of slightly over an inch — half an inch radius from each puncture being 
the zone of absolute anaesthesia produced by such an injection. This 
anaesthesia is produced in three minutes, and lasts about twenty-five 
minutes, and provided not more than twenty drops are used at one 
time, the cocaine is not likely to produce any syncope or other ill effects. 
Schleich finds that a -02 per cent solution produces anaesthesia after 
injection, and even distilled water has some anaesthetic effect. 

After such an injection of cocaine, operations like trachelorrhaphy, 
perineorrhaphy, excision of a retention-cyst of Bartholini's gland, or 
burning off a vascular urethral caruncle may be performed without 
suffering. It has been asserted, however, that union is often less com- 
plete, and repair less rapid, after operation performed with locally 
induced anaesthesia. 

If a caruncle be present, anaesthesia may be desired before cathe- 



G YN^COL O GICA L THERAPE UTICS 



273 



terisation, and an ointment (8 per cent) may then be gently applied ten 
minutes beforehand. A similar ointment may be useful in cases of 
vaginismus or dyspareunia from a local hypersesthesia, coitus being thus 
rendered possible. For this purpose, as also for the relief of pruritus, 
as in kraurosis vulvae, its use is, as a rule, but a temporary expedient, 
operative measures being generally needed to effect a cure. 

(h) General Anaesthesia. — The choice of the anaesthetic is a subject 
which should not be solely in the hands either of the operator or of the 
anaesthetist, but the operator should state which anaesthetic he prefers. 
If the anaesthetist, after noting the type of patient, and listening to the 
heart and lungs, be satisfied that that particular anaesthetic is not contra- 
indicated, he will acquiesce; if, however, he consider another form of 
anaesthesia to be more suitable for the particular patient, a friendly con- 
sultation would no doubt lead to the adoption of his advice. Some 
operators pin their faith to a certain form of anaesthesia as the best for 




Fig. 67. — Junker's inhaler. 

certain operations ; but inasmuch as patients vary greatly, the choice 
must ultimately be made after a consideration of the patient's state, and 
as the responsibility finally rests with the anaesthetist, it is right that he 
should be always consulted and his views upheld. 

Although much depends on the skill of the administrator, it is 
probably true that there is more bleeding during ether anaesthesia, and 
thus, caeteris paribus, such operations as perineorrhaphy or vesico-vaginal 
fistula are easier to perform under chloroform or A. C. E. mixture ; 
sickness is usually more marked after ether, and spasmodic, laboured, 
or jerky breathing is apt to be present during its administration: for 
this reason many prefer chloroform for abdominal operations, especially 
when administered by means of a Junker's inhaler (Fig. 67), but it is 
fair to say that in the administration of ether by a few anaesthetists these 
objections are not experienced. Ether should not be used where the 
abdomen is much distended, or where from other, especially pulmonary 
conditions, the respiration is laboured. In operations requiring very 
deep anaesthesia — as in rapid dilatation of the cervix uteri for digital 
exploration of the uterine cavity — there is no doubt that ether is safer 



274 • SYSTEM OF GYNECOLOGY 

than chloroform, as it can be "pushed" to a further degree without 
risk. 

After loss of large quantities of blood ether is safer than chloroform. 

The scope of this work forbids further reference to the details of the 
administration of the various anaesthetics. 

8. Therapeutical Operations.— (i) Dilatation of the Uterus. — This 
operation was introduced by Simpson in 1844, and may be required for 
various purposes. Dilatation may be complete so as to admit the linger, 
or merely partial, to facilitate curetting or intra-uterine medication. 

Complete dilatation is mainly effected for diagnosis by digital ex- 
ploration, or for treatment of some condition otherwise diagnosed. It 
is most frequently employed for the purpose of discovering the cause of 
an intra-uterine haemorrhage; and the dilatation must, for that object, 
be sufficient to admit the introduction of the little, or if need be, of the 
index finger of the operator. 

Partial dilatation is practised for the treatment of some cases of 
dysmenorrhoea and sterility ; or prior to the application of some caustic 
or counter-irritant to the endometrium ; or for the purpose of curetting 
in cases of haemorrhage or chronic purulent endometritis, where the 
uterus is not much enlarged and digital exploration not needed. 

In all cases, however, where a diagnosis cannot be made by the 
examinations of portions of the endometrium detached by the curette or 
other instrument, or where polypus, carcinoma, or other disease, cannot 
be excluded by other evidences, it is far wiser to make sure of the nature 
of the case by dilating so as to admit the finger. 

Both degrees of dilatation should preferably be performed immediately 
after the cessation of a period ; then the cervix is softest, and is also 
somewhat patent. This softness (p. 281) and relaxation are greatly 
increased by the introduction of a glycerine tampon two hours beforehand 
by the nurse ; and dilatation becomes still more easy if the physician 
insert into the cervix, as described hereafter, a piece of gauze saturated 
with glycerine and iodoform about six hours before the operation. 

Methods of dilatation : — 

A. Gradual dilatation : a. By antiseptic wool or gauze. /?. By tents. 

B. Rapid dilatation : a. By graduated bougies, p. By two or three- 
bladed dilators, y. By miscellaneous methods. 

C. Combined gradual and rapid methods. 

D. Dilatation with incision. 

A. Gradual Dilatation : — a. By Antiseptic Wool or Gauze. — This 
method was introduced by Vulliet in 1886, and is easy of execution ; 
if antiseptics are rigorously used, and suitable cases selected, no danger 
should arise. 

The vagina and vulva should be previously rendered antiseptic by 
douching and washing, and the vagina temporarily distended with an 
iodoform gauze tampon. The cervix should be exposed by a Sims' or by 
a diverging speculum, such as Griffin's (Fig. 68), Cusco's (Fig. 69), or 
Neugebauer's (Fig. 58, p. 263), and the anterior lip should be seized by a 



G YN^ COL O GICAL THERAPE UTICS 



275 



volsella and held steady at a somewhat lower level than normal. The 
endocervix should then be cleansed, and the direction of the uterine canal 



..--r' 




Fk;. CS. — Griiiin's speculum 



ascertained by a sound ; if the os interum be found to be small, a few 
bougies may be passed. A strip of gauze, a quarter to one inch wide 
(according to the estimated size of the canal), is then dipped in carbolised 
or iodised glycerine, and is introduced by doubling it over the end of a 
uterine gauze applicator (Fig. 70). This instrument should taper some- 



If pnwfKiF f r o^i^MPiniSl 



Fig. to. — Gauze applicator (whalebone). 



what towards the end, which should be blunt-pointed, and not so fine 
as to penetrate the gauze. Gauze may also be introduced on long, 
narrow-bladed forceps (Fig. 71). 




Forceps to introduce gauze. 



After the cervix has been completely or even partially dilated, some 
operators prefer to tampon its cavity through a cervical speculum (Fig. 72). 
The gauze should be carried up to the fundus and the probe withdrawn, 
and more gauze similarly introduced, till the cavity is somewhat tightly 



276 SYSTEM OF GYNECOLOGY 

packed. Vulliet preferred to dilate by wool tampons, varying in size 
from a pea to an almond, rendered antiseptic by dipping in a 10 per cent 
ethereal solution of iodoform. 

Whether gauze or wool have been used it is withdraAvn after twenty- 
four hours, and the cavity carefully cleansed with sublimate swabs. 
Eresh gauze is then similarly introduced, and, after the third introduc- 
tion, the cervix will be so softened and dilated as to admit the finger. 

The advantage of this method is that it is nearly painless, but un- 
less great care be taken not to injure the endometrium, it is certainly not 
free from the risk of septic absorption. As a preliminary accelerant 
of rapid dilatation it is excellent, but even then great care has to be taken 
to avoid rough introduction of the gauze. To lessen this risk of septic 
absorption through lesions accidentally made, gauze should never be thus 
used if the uterine discharges be offensive. 

If it be desired to keep the uterus patent after either rapid or slow 




Fig. 72. — Cervical speculum (Bantock's). 

dilatation, — as, for instance, when it is hoped to obtain the extrusion of a 
submucous fibroid whose capsule has been incised, — continuous packing 
of the endometrium will usually ensure the safety of the patient in the 
frequent case of danger from sloughing of the fibroid. Such packing 
will further dilate the uterus and render any subsequent manipulations 
easier. 

In some cases of chronic endometritis a partial dilatation and drainage 
by gauze, with the application of iodine liniment or paint twice weekly 
whilst drainage is continued, will often cure the condition in a fortnight, 
the patient meanwhile keeping to her room. Curetting is, however, in 
most cases far preferable. 

^. Gradual Dilatation by Tents. — According to More Madden sponge 
tents were invented by Phillip Barrow in 1539 ; but the method was so 
far forgotten that when Sir James Simpson revived their use, in 1814, he 
stated that " intra-uterine disease was generally considered beyond the 
pale of any certain means of detection or possibility of removal." 

The tents mostly used are laminaria (introduced by C. F. Sloan of 
Ayr in 1862), sponge, and tupelo. Gentian root and decalcified ivory 
are also used by Porak. Laminaria tents, as sold by instrument 
makers, are unreliable as regards antisepsis; and it would be worth 
while for any gynaecologist who uses them much to collect and prepare 
his own, an easy undertaking. Sponge tents are even more difficult to 
get antiseptically clean. The results of using tents not absolutely 
aseptic are most disastrous, and have caused many a death ; in the pre- 



G YN^COL O GICAL T HER APE UTICS 



77 



antiseptic days, acute metritis, salpingitis, peri- and para-metritis and 
septic fever were frequent consequences. 

Laminaria and tupelo tents should be steeped in a saturated solution 
of alcohol and corrosive sublimate for two or three hours, and then 
allowed to dry before being used ; sponge tents may be dipped in an 
ethereal solution of iodoform (10 per cent), and then dried by swinging 
them round by the attached string. 

Tents are mainly used as a preparatory step to rapid dilatation; but 
they are still used sometimes for completing dilatation, and must then be 
repeatedly introduced till the finger can be inserted. I have not used a 
tent for several years, as I find rapid dilatation answers all purposes when 




Duckbill speculum (Sims' 



used with the aids described on pages 280-1, but, as it is evident that tents 
are still frequently used, full details of their introduction are here given. 
After the tents and the vagina have been prepared, and the patient 
put into the Sims or lithotomy position, a duckbill speculum (Fig. 73) 
is introduced, and the cervix somewhat lowered by a sharp hook, so as 
to fix the uterus and straighten its canal. The actual length and curve 
of the cavity is then ascertained by the sound, and the size of the tent 
which can probably be introduced is roughly gauged. A laminaria tent 
can be curved by holding it over a spirit lamp till hot. The cervix should 
then be cleansed with sublimate solution, and the tent passed either on a 




Fig. 74. — Barnes' tent introducer. 



pointed introducer provided with a canula, such as Barnes' (Fig. 74), or 
held in a suitable pair of forceps, such as Chambers' (Fig. 75). It is a 
good plan to dip the tent into pure liquid carbolic acid before inserting it. 



278 SYSTEM OF GYNECOLOGY 

As large a tent, or as many small ones, as can be passed beyond the os 
internum should be inserted at once. The ends should slightly project 
into the vagina. A vaginal antiseptic tampon soaked in glycerine should 
then be inserted. The tents should be left in from eight to twelve hours, 
especially the hollow laminaria ones, as they do not readily dilate to 
their full extent at the os internum, where there is greatest resistance. 
To extract a tent, all that is necessary is to draw upon the string at- 
tached to the vaginal end ; but if the tent has not dilated well at the 
level of the os internum, forceps must be used to pull and lever it out, 
whilst counter-pressure is exerted upon the cervix by the finger. 

To admit the exploring finger into the uterus, one, or often two 
repetitions have to be made. This should only be done after careful 
antiseptic cleansing both of the vagina and uterine cavity ; and then as 
many fresh tents as can be introduced should be simultaneously inserted. 




Fig. lb. — Chambers' teut introducing forceps. 

If only a slight further dilatation be necessary, and rajoid dilatation 
be not available, a tupelo tent is better than another series of laminaria, 
as it dilates more rapidly and more evenly, can be obtained of larger 
size, and be more efficiently rendered antiseptic. By this time, especially 
if a third series of tents have been introduced, the temperature may have 
risen, the patient will be irritable and restless and sometimes nauseated, 
and not in the best condition to undergo a prolonged examination for 
the purpose of treating whatever conditions may be found. 

In the old days, when the uterus was always dilated with tents, it was 
not often that any condition was found which required, or at all events 
was treated by curetting ; this is to be explained by the fact that the 
prolonged pressure of three series of tents, with the application of the 
intra-uterine counter-irritants subsequently used, would destroy any of 
the more ordinary hypertrophic fungosities found in so-called " fungous 
endometritis," and would, if no accidents followed, tend to promote 
absorption of inflammatory exudations in the parenchyma of the organ. 
In curetting we have now, however, a much more rapid and effectual 
method of dealing with these conditions. 

Tents should never be used if the uterine discharges are offensive, as 
the absorption of pent-np putrescent secretions may lead both to local 
septic inflammation and to a general septicaemia; and, even recently, 
deaths have been described as having occurred under these conditions. I 
refer to such cases as cancer of the body of the nterus, sloughing polypus, 
and even to some cases of fungous endometritis in which the polypoidal 



GYNECOLOGICAL THERAPEUTICS 279 

villous processes of gland tissue have either become ulcerated or have 
superficially sloughed. JSTo tent should ever be used twice. 

It must be remembered that the danger of sepsis is not over when the 
tents have been removed, as, especially with sponge tents, small pieces 
are apt to remain in the folds of the lining membrane, and will there 
decompose and cause a local absorption. It is therefore most important 
that after the withdrawal of tents some strong antiseptic should be 
carried up into the uterine cavity, such, for instance, as iodine liniment 
or iodised phenol ; and that drainage should, for twenty-four hours, be 
maintained by passing up into the uterus a thin strip of iodoform gauze 
soaked in iodised glycerine. 

Every now and again it is found that the effect of the introduction of 
a tent upon the nervous system is considerable ; the patient becomes 
extremely restless, or vomits incessantly, or the temperature rises imme- 
diately, or at all events too soon for it to have a septic origin ; a few 
cases of convulsions have been described, and one or two of tetanus. In 
one case, treated by myself, the temperature rose to 107° F. within 
thirty minutes of the insertion of the tent ; but under the influence of 
a hypodermic injection of morphia it gradually fell, and by the next 
morning, on removal of the tent, it was 99° F. ; the patient recovered 
without further trouble. Bromide of potassium is very useful to control 
this hypersesthesia and excitement. 

B. Kapid Dilatation. — Dilatation by tents, except as a preliminary 
step, having now been almost universally given up, all the exploratory 
and therapeutical dilatations are performed either entirely, or in the 
main, by one or other of the rapid methods. Whereas it used to take 
from twenty -four to forty-eight hours to dilate the uterus sufficiently to 
admit the exploring finger, it is now done with far less risk in from 
twenty to sixty minutes. 

Indications for Bapid Dilatation. — Bapid dilatation may have to be 
done for the treatment of some forms of dysmenorrhoea, as for instance in 
some cases of the spasmodic or of the obstructive type, and especially in 
cases of membranous d3^smenorrhoea ; as a preliminary step to a thorough 
application of some medicament to the endometrium, or antecedent to a 
subsequent curettage ; or in some of those rare cases where, according to 
Schultze, it is advisable to dilate the uterus sufficiently to admit the 
finger, with a view to breaking down retro-uterine adhesions by manipu- 
lation, and so to perform " intra-uterine reposition." The main object of 
rapid dilatation, however, is to enable the finger to be introduced for the 
purpose of making a diagnosis of the intra-uterine condition in cases of 
uterine hsemorrhage, where, in the absence of any constitutional cause or 
obvious local extra-uterine disease, a further examination is indicated. 

Assuming, then, that a woman comes for treatment, one of whose 
chief symptoms is menorrhagia or metrorrhagia, inquiries would be made 
as to any constitutional cause, and a vaginal examination would be made, 
unless contra-indicated by virginity or youth. In all cases of haemorrhage 
after the menopause, or even in cases of severe haemorrhage before that 



28o SYSTEM OF GYNECOLOGY 

time of life, a vaginal examination should be insisted upon to make tlie 
diagnosis sure. Possibly some obvious cause of haemorrhage would thus 
be discovered, such as cancer or adenoma of the cervix or vagina, adhesive 
ulcerative vaginitis, severe erosion of the vaginal portion, ulceration from 
foreign bodies, an extruding fibroid, a cervical mucous polypus, ulcerating 
procidentia, or inversion of the uterus. The possibility of a molar preg- 
nancy, a threatened, incomplete, or missed abortion, or the existence of 
a mole or an endometritis of the gravid uterus, must not be overlooked. 

A bimanual examination would further serve to limit the diagnosis, 
when the uterus might be found uniformly enlarged by subinvolution, or 
irregularly so by intramural fibroid ; or some tubal or other perimetric 
disease might be found to account for the haemorrhage. If none of these 
obvious causes were discovered the sound might be passed, whereby the 
size and shape, and any considerable roughness and vascularity of the 
endometrium would be discovered. If the uterus be not enlarged con- 
stitutional treatment may be tried ; or if an ordinary endometritis be 
diagnosed in a small uterus, a partial dilatation, prior to the use of some 
counter-irritant, may be effected without anaesthesia, or after the local 
application of a 10 per cent solution of cocaine. Even if the uterus be 
irregularly enlarged, and intra-mural fibroids be diagnosed, it must not 
be assumed that the haemorrhage, which is probably the main symptom, is 
to be dealt with by a serious operation like oophorectomy or hysterectomy, 
for, as I (25) have elsewhere shown — in a series of consecutive cases 
dilated for haemorrhage — 88 per cent of the cases of fibroid uterus thus 
treated contained a removable cause ; that is, they were found compli- 
cated with fungous endometritis, polypus, or the two combined, and were 
thus capable of immediate relief, so far, at least, as the immediate symp- 
tom of haemorrhage was concerned. By this means the patient would 
often be steered safely over the menopause. 

Many cases are now on record, and others are within the knowledge of 
all gynaecologists, where haemorrhage has persisted after oophorectomy, 
and has been subsequently cured by the removal of an intra-uterine 
polypus after exploratory dilatation. 

Aids to Rapid Dilatation. — There are many uteri which are difficult 
to dilate sufficiently to admit the finger, and it is impossible to decide 
beforehand which cases will prove so resistant. It used to be said that 
if it were impossible to dilate a cervix, this was a fair proof that it was 
affected by malignant disease. As a rule a cervix is only materially 
resistant if there be an intramural fibroid involving part of its circumfer- 
ence, and also in some nulliparous women, but only twice in my experi- 
ence has this been sufticient to prevent digital exploration. There are aids 
to dilatation, rendering it easier, quicker, and less dangerous, which it is 
desirable to emphasise ; for it is rare to find that anything has been done 
to prepare the patient before the actual operation, except perhaps from 
the antiseptic point of view. First of all, it is infinitely easier to dilate 
a cervix if the day following the cessation of a period is chosen. The 
tissues are softer, and the cervix is somewhat patent. This was first 



GYNECOLOGICAL THERAPEUTICS 281 

noted by Dr. C. H. P. Eouth in 1864; recently Dr. Braithwaite has 
drawn special attention to this fact, and Dr. Herman has shown that 
this relaxation is most marked on the third and fourth days of ordi- 
nary periods ; but it is better to await the cessation of the period 
before attempting dilatation. Secondly, the cervical glands should be 
encouraged to secrete, for, as Dr. Champneys has said, dilatation is 
physiological, and the cervix has to be induced to yield. When it yields 
it also secretes, as in pregnancy and labour. When the cervix is moist it 
is dilatable ; when dry it is rigid ; and, in this latter condition, any 
attempt at rapid dilatation is generally a failure, and might cause exten- 
sive tearing. Many writers consider the best way to overcome this rigid- 
ity is by preliminary partial dilatation by tents ; but it is evident that 
there may be danger in this also, as well as several hours' discomfort to 
the patient. 

The cervix can be induced to secrete freely by inserting into the 
vagina, two or three hours before the operation, a wool tampon soaked in 
glycerine, or less effectually by a gelatine and glycerine pessary. The 
effect of the glycerine is enhanced by the addition of a little cocaine, 
which serves to relax local spasm, as it does in rigid cervix in the first 
stage of labour. In either case the glycerine should be applied close up 
to the external os uteri. Secretion is further helped by giving a warm 
vaginal douche of borax or creolin solution before introducing the gly- 
cerine tampon. 

If unusual difficulty be anticipated, owing to nulliparity, advanced age, 
or the presence of fibroids, additional help is afforded by passing into the 
cervical cavity, and if possible through the os internum, some gauze 
saturated with glycerine and iodoform. This may be introduced from six 
to twelve hours before the operation, which it greatly facilitates by relax- 
ing the muscular fibres, and partly dilating the canal. As has been 
stated this preliminary gauze packing should not be adopted when there 
is an offensive discharge. These '^ aids " practically obviate the need for 
a preliminary dilatation by tents in all but very exceptional cases. 

Methods of Rapid Dilatation. — Assuming, however, that rapid dilata- 
tion has been decided upon for the purpose of making a diagnosis of the 
intra-uterine condition to which is due the hsemorrhagic, purulent, and 
possibly offensive discharge, there are several ways by which this can be 
effected, namely : i. By graduated bougies ; ii. By two, three, or four 
bladed dilators with or without attached screws ; iii. By miscellaneous 
instruments. 

a. Eapid Dilatation by Graduated Bougies. — In England dilatation by 
bougies is preferred ; and when carefully and antiseptically conducted, it 
is free from risk, sufficiently speedy in its performance, and effectual in its 
results. Hegar's bougies were first introduced to the profession in 1881, 
but were not in general use in this country till eight or ten years later ; 
when amongst others Drs. Lewers and Phillips drew special atten- 
tion to their value. Hegar's original dilators were rather short, and 
made of polished wood or ebony ; they consequently gave rise to a good 



282 



SYSTEM OF GYNECOLOGY 



deal of friction, and were if anything too sharply pointed. To overcome 
these disadvantages Hegar's dilators (Fig. 76) are now made longer, and 

the metallic bougies now 
used are often made about 
the same length as a male 
catheter, with a sharper 
curve than Hegar's, and 
are constructed of hollow 
metal tubes, with ends 
somewhat less pointed. 

There are numerous va- 
rieties of metallic bougies, 
with varied details in the 




Fig. 76. 



uterine dilator (Hegar's improved). 

length, the shape of the point, the curve, the weight, and the handle. 
Among these may be mentioned those of Matthews Duncan, Galabin, 
Macnaughton Jones, Heywood Smith, Peaslee, Godson, John Phillips, 
and Hayes. Those of the last type (Fig. 77) and Matthews Duncan's 
(Fig. 78) are probably the best. 

The best size to be.o^in with is one with a diameter of four milli- 




KROHNE & C5 LONDON )25 




KROHNE & C LONDON 



© 



Fig. 77. — Uterine dilators (Hayes'). 

metres, and each succeeding size should vary in diameter not more than 
one millimetre. These bougies should be numbered according to their 
diameters. A case is occasionally met with where one millimetre seems 
too large a difference ; and it is therefore advisable for hospital use to 
have some made with half a millimetre difference. In private, the diffi- 
culty is overcome by giving more time, or by having always in the bag 




Fig. 7S. — Uterine dilator (Matthews Duncan's). 



a Goodell's two-bladed parallel dilator (Fig. 83), which will speedily over- 
come the resistance, so that the next sized bougie may be used. Such 
metal bougies as these involve very little friction, follow the pelvic and 
uterine curve easier, and, owing to their greater length, allow greater 
facility of manipulation. Their points being less tapering they also dilate 
the uterus right up to the fundus. 

With these bougies, and with accelerants to dilatation as suggested, 
the usual time taken to dilate the uterus so as to admit the finger is 
about fifteen or twenty minutes. Thus I myself dilated and digitally 



G YN^COL OGICAL T HER APE UTICS 



283 



explored the uterus in two patients for liseniorrliage ; curetted both for 
fungous endometritis ; dilated another uterus for dy smenorrhoea, all under 
ether ; and performed another small operation under gas, in exactly sixty 
minutes, without unusual haste. 

The Operation. — The patient having been duly prepared by previous 
purgation, the vagina having been douched, and all antiseptic precautions 
having been taken as already described, the patient is anaesthetised, with 
ether for choice, and is placed either in the lithotomy position — Clover's 
crutch (Fig. 79) being employed to keep the legs up — or else, as some 
prefer, in the Sims' position. 




Fig. T9. — Clover's crutch. 



The vagina is then again cleansed with a 1 in 2000 sublimate solution, 
and the operator's hands and the instruments being prepared as stated, 
the anterior lip (the uterus being assumed to be anteverted) is seized with 
a volsella forceps, drawn downwards, and held steady. This straightens 
the uterine curve, and prevents the strain on the ligaments which must 
occur if the bougies are passed without the uterus being thus fixed. A 
uterine sound is next introduced to ascertain the exact curve of the 
uterine cavity when thus drawn down ; and then the smallest sized bougie 
is steadily passed, so that it may not be jerked through the internal os 
uteri as its spasm passes off, and perhaps made to impinge roughly 
against the fundus. 

Some recommend that the operator should hold the volsella forceps 
whilst passing in the bougie so as to estimate the amount of force being 
used, but this is not advisable. An assistant should hold the cervix 



284 SYSTEM OF GYNAECOLOGY 

immovably, and the operator should then pass up two fingers (a speculum 
should not as a rule be used) to the cervix, and introduce the bougie along 
them ; with some experience, the operator can estimate very accurately 
how much force he is employing. It is important to use a volsella 
forceps which will not readily tear or cut its way out, and for this reason 
Teale's forceps (Fig. 80), which has several blunt teeth on each face, is the 
best, as it seizes the anterior lip bodily, and if the racket on its handle 
is efficient it practically never slips off. 

The time which should elapse between the passage of succeeding 
bougies varies greatly. If a bougie has been introduced with difficulty, 
time should be allowed for it to get loose by relaxation of the cer- 
vical fibres ; this can be tested by partially withdrawing it and 
feeling whether it has become looser in the grip of the os internum. 
Perhaps one to three minutes may be needed for this relaxation to occur, 
but as a rule a few seconds suffice. An assistant should remove the 




Teale's forceps. 



bougies, when the operator has ascertained that they are ready for 
removal, and should dip them in warm carbolic solution in case the 
operator should find that the next size will not enter, and the previous 
size be again required. By allowing an assistant to remove each bougie, 
the operator is enabled to have in his hand the next sized bougie, ready, 
warmed and oiled, for immediate insertion. This is an important detail, 
as the spasmodic contraction of the cervix, even under deep ansesthesia, 
is remarkably persistent, the pelvic reflexes not being annulled till after 
the conjunctival reflexes are quite absent. 

The extent of the dilatation required will vary according to the nature 
of the case. If a digital exploration be required, it is usually sufficient to 
dilate so as to admit the little finger, especially if the cervix can be 
drawn well down. This will enable the operator to diagnose a polypus, 
malignant disease, or fungous endometritis ; but he must not be satisfied 
till he has succeeded in feeling, if possible, the whole of the endometrium, 
including the two cornua, which are favourite spots for placental polypi 
and hypertrophic endometritis. The finger can explore uteri which are 
considerably longer than the examining finger if the other hand be used 
to press down the fundus from over the pubes ; care being taken that the 



G YNJE COL O GICAL THE RAPE UTICS 



bladder is empty. If malignant disease be diagnosed, no further dilatation 
is required, hysterectomy being needed if otherwise indicated ; or if the 
diagnosis be uncertain, the curette or scissors will be wanted to remove 
a piece for microscopical examination. If a fibroid polypus be found, 
further dilatation may be needed to admit the scissors, forceps, or wire 
ecraseur along the finger. If fungous endometritis be detected a curette 
can be at once used. If a bit of placenta be found, it may usually be 
detached by the finger tip. 

Sometimes the diagnosis of fungous endometritis is made after the 
passage of a few bougies, by pieces of characteristic material coming away; 
but it is only safe to accept this as the sole condition in small uteri, as 
it is not unusual to find this state of the endometrium complicating 
both submucous fibroid and poh'pus. 

It is evident that the amount of dilatation for exploratory pur- 
poses really depends upon the size of the operator's little finger, or 
rather upon the size of the second joint of that digit ; and this is a matter 
of considerable moment, as fingers vary several millimetres in diameter, 




Fig. SI. — Budin's tube. 

and any risk to the patient is necessarily proportional to the amount of 
dilatation required. It is for this reason that diagnosis should be made 
by the little finger, and not, in cases of rigid cervix at all events, by the 
index finger. Usually the fingers of the left hand are smaller than 
those of the right. 

Whatever be the object of the dilatation, and whatever be the subse- 
quent procedure (curetting, removal of polypus, etc.), it is advisable to 
apply to the endometrium some strong antiseptic counter-irritant, such 
as iodine liniment or iodised phenol, on a Playfair's probe, which should 
be covered with as much wool as will easily enter the dilated cervix. 

To permit free drainage, and to prevent uterine colic following the 
application of the iodine, a piece of iodoform gauze should be passed up 
to the fundus in the manner previously described, and should not be 
removed till next morning when the vagina will also be douched. 

Some operators prefer not to apply any antiseptic after dilatation, 
unless purulent endometritis is present, or the discharge indicates the 
existence of a septic intra-uterine condition. It is advisable, however, if 
this be not done, and if a flushing curette be not subsequently used, to 
wash out the uterus thoroughly with iodised or carbolised water at a 
temperature of about 118° P., by means of a double-channelled tube of 



286 SYSTEM OF GYNECOLOGY 

glass or celluloid, such as Budin's (Fig. 81), or Graily Hewitt's glass 
tube (Fig. 82), or a metallic one, such, as Bozeman-Fritsch's. 

The Dangers of Eapid Dilatation. — The risk of rapid dilatation is very 
small if carried out thus. There is hardly ever any subsequent pyrexia ; 
if there be, it is almost always in cases where malignant disease has 




Fig. 82. — Graily Hewitt's uterine tube. 

been diagnosed, and then probabl}^ arises from septic absorption. In 
cases of tubal disease there is sometimes a little inflammatory reaction ; 
but if free drainage be provided this soon passes off, and any chronic 
salpingitis, which existed as a sequence to the concurrent endometritis, 
often disappears within a few weeks (G. H. F. Routh, Doleris, Trelat). 
"Lumps in the pelvis," such as are due to ovarian congestion or swollen 
tubes, are not necessarily contra-indications to rapid dilatation, for slow 
dilatation by tents would be more risky (see curetting). 

If by some accident — such as roughness on the part of the operator 
or, as more often happens, in extreme softness of the uterine tissues, 
as in some cases of subinvolution, or where the tissues are friable as 
in carcinoma — perforation of the uterus has occurred, serious results 
may not follow, provided that antisepsis has been thorough, and 
recognition of the accident immediate. The proper treatment in such 
cases is to cease further dilatation, and after cleansing the vagina and 
endocervix, lightly to pack the uterine cavity with gauze. In a few 
hours lymph will have covered over the perforation, and probably no 
symptoms beyond some sickness will ensue. All cases of perforation do 
not terminate thus satisfactorily, but these are either in themselves septic, 
or antiseptics have been neglected ; or the accident has not been recognised, 
and more bougies have been passed, possibly even a curette used, and the 
bowel injured. Fortunately such accidents are very rare, but the possi- 
bility of the uterine tissue being extremely soft must be kept in mind. 
If it be realised that the perforation through the uterus is extensive, or 
the uterine contents septic, or that the bowel have come down into 
the uterine cavity, the abdomen may be opened ; and if the rent cannot 
be sutured hysterectomy should be performed : some operators would 
at once proceed to perform vaginal hysterectomy, being particularly 
careful to ensure subsequent good drainage by gauze. 

If the cervix be rigid, slight lacerations of the mucous membrane 
usually occur, and occasionally when the exploring finger is introduced 
rather deep splits are found, usually on the left side ; but in a series of 
several hundred cases I have never seen permanent mischief result, or 
even inflammatory troubles follow. Such tears seem to commence at the 



G YN^ COL O GICAL T HER APE UTTCS 



287 



level of the os internum, and may be suspected if a bougie pass easily 
after the preceding smaller size entered with difficulty. 

Occasionally haemorrhage suddenly arises during a dilatation, as for 
instance when a piece of placental polypus becomes detached, appearing, 
it may be, at the os externum when the bougie is withdrawn. \xv such 
a case the haemorrhage is sometimes alarming, and time cannot be wasted 
by attempting further dilatation with a view to exj^lore with the finger 
— though it may be worth while to pass in the curette and rapidly scrape 
the endometrium to remove any more placental tissue, and thus encourage 
retraction : but if the haemorrhage persist, as it probably will, the uterus 
should be plugged at once with antiseptic gauze, and the plugs retained 
in utero for twenty-four hours, by which time the uterus will be sufficiently 
dilated to admit the finger if necessary. The haemorrhage appears to be 




Tig. S3. — Goodell's two parallel-bladed dilator. 



arrested by pressure and by the blood coagulating readily upon the gauze 
fibres, and not, at all events, solely by the uterus being excited to con- 
tract by the presence of a foreign body : for it is evident that even if 
contraction and retraction of the muscles at the site of the hgemorrhage 
be the immediate effect of the gauze-packing, a secondary effect is a 
further passive dilatation and relaxation, and yet haemorrhage does not 
then recur. 

/S. Kapid Dilatation by Two and Three Bladed Dilators. — There are 
some who prefer this type of dilator, but none of these instruments has 
met with universal approval, owing to the irregular way in which they 
dilate, the time occupied by the process, the more frequent failure, and 
the greater tendency to tearing of the cervix. There is, however, a great 
advantage in having one of these instruments at hand when dilating Avith 
bougies, as it occasionally happens that the operator finds it difficult to 
pass the next sized bougie, or possibly a particular bougie may have been 
forgotten. The possession of a dilator of this type, like Goodell's, is then 



288 



SYSTEM OF GYNECOLOGY 



most opportune, and its employment will enable the further dilatation 
to be made with the other bougies. 

The preliminary steps are identical with those required for dilatation 
by bougies, both as regards antiseptics, anaesthesia, and the position of 




Fig. 84 



the patient. The cervix must also be seized and steadied, and the uterus 
drawn down ; it is advisable to use a duckbill speculum, so as to introduce 
and screw up the dilator by the aid of inspection. The best instruments 
are Goodell's (Fig. 83) or Ellinger's two-bladed dilators (Fig. 84), or 
Sims' three-bladed dilator (Fig. 85). The two former are the best, as 
they dilate by parallel blades. 



(■<'\ 



X 




Fig. 85. — Sims' three-bladed dilator. 



For the employment of all these instruments the cervix should be 
somewhat patent ; and if it be found that they cannot enter the cervix 
above the os internum, a smaller sized dilator, such as Palmer's two-bladed 
dilator (Fig. 86), should be first used, or a few bougies passed. The most 
important precaution in dilating by these instruments is to avoid screw- 
ing up the blades in one diameter of the cervix only. They should be 
opened very gradually in the transverse diameter first, then unscrewed 
and rotated, and again opened in another diameter, and so on till disten- 
sion of the muscle fibres has been uniformly effected all round. In a 
soft, relaxed cervix dilatation can be easily effected by this means ; but 
in the nulliparous rigid cervix complete dilatation is often impossible, 
or if possible, open to serious risk. 

In cases of dysmenorrhoea, where moderate stretching is to be effected 
as a method of treatment, dilatation by these instruments is fairly satis- 
factory ; and if it be desired to attempt a partial dilatation without 
anaesthesia, a small-bladed instrument like Palmer's, Priestley's (Fig. 87), 



G YN^COL GICAL T HER APE UTICS 



289 



or Collins' may be passed in, and a few turns given to the screw. Some- 
times great improvement follows as regards the pain and sickness usually 
accompanying the period, which should not be more than two or three 




^Z. SCALE. 

Fig. S6. — Palmer's two-bladed dilator. 




Fig. 87. — Dilator Fig. SS. — Uterine dilators 
(Priestley's). (Eeid's). 



days distant. The danger of such a partial proceeding is that there is a 
risk of neglecting complete antisepsis, and serious inflammation might 
then follow. There are many instruments on the same principle, such as 

u 



290 SYSTEM OF GYNAECOLOGY 

Gardner's, Wathen's, Buck's, Simpson's, Pearson's. Some of these are 
worked by hand-pressure, some by screws. 

y. Rapid Dilatation by Miscellaneous Instruments. — Such instru- 
ments are numerous. A few will suffice as types. Dr. E-eid of Glasgow 
has invented a conical screw dilator, with different-sized screws. They 
answer well in the inventor's hands, or when his instructions are fol- 
lowed ; but his method is not satisfactory in cases of rigid or indurated 
cervix, as unless the tissues yield readily the biting of the conical screws 
causes abrasion of the lining membrane. Mr. Lawson Tait, again, has some 
conical dilators, wdiich are, however, only " rapid " Avhen compared with 
tents, for two or three hours at least are required for each sized conical 
wedge to do its work. They are cones fixed to a vaginal stem or holder 
attached to elastic bands, which pass up, two in front and two behind, to 
be fastened to a belt or waistband. By regulating the tension of these 
bands the direction and amount of pressure can be arranged; but inasmuch 
as tiiese details require careful watching and readjustment, the method 
is only suitable for hospital work, and it is clearly capable of causing 
dangerous upward pressure if by any accident the bands are not loosened 
when the dilatation of the cervix is completed. Fritsch has also in- 
vented some conical dilators, to be used manually just as the graduated 
bougies are used. 

More Madden's dilator is two-bladed, but instead of dilating equally 
along the cervix, it dilates from its upper end, where the ends most 
diverge ; so that the uterus is dilated first, then the os internum, and 
gradually, as the instrument is drawn out, the endocervical canal becomes 
stretched. It is no improvement upon such instruments as Goodell's 
two-bladed dilator. 

Duke's two-bladed dilator has a more decided curve, and its blades, 
which open by a powerful screw, are conical in shape. 

Eeverdin uses a two-bladed dilator with one blade hollowed out for 
flushing, and he states that dilatation is accelerated by the continuous 
flow of a warm antiseptic solution. 

C. Combined Gradual and Rapid Dilatation. — After failing to dilate 
the cervix to the " exploratory " size by rapid dilatation, it is not safe to 
continue the dilatation with tents until the abrasions have healed. The 
mucous membrane is necessarily torn here and there after such a trial, 
and septic absorption is very prone to occur. In such a case the best 
plan is to antisepticise the endometrium thoroughly, and then to pack 
the cavity gently but firmly with 10 per cent iodoform gauze, as before 
described. This will efficiently dilate the uterus in twenty -four hours 
without any appreciable risk. 

Previous to rapid dilatation in nulliparous women, it is the routine 
custom of some operators to dilate the cervix partially overnight by means 
of tents, preferably laminaria. This undoubtedly softens, and begins to 
dilate the cervix, but is rarely necessary, as it usually gives the patient 
a very uncomfortable night; and if the aids to rapid dilatation described 
on page 280 be made use of, this preliminary dilatation can be dispensed 



GYNECOLOGICAL THERAPEUTICS 291 

with, or accomplished much more safely, with far less discomfort and 
quite as effectually, by stuffing the endocervix with gauze, as described 
on page 274. 

D. Dilatation with Incision. — Occasionally the os uteri externum 
remains rigid, while the rest of the cervix has become relaxed and 
dilatable ; it may then become necessar}^ to divide the rigid rim bilater- 
ally. A common instance of this is where an intra-uterine polypus has 
been partly extruded, and has fully dilated the whole cervix, except a 
rim of rigid tissue at the os externum. Here a slight notch on each side, 
the loss of a little blood, and the yielding of the rigidity, will afford suffi- 
cient space, and dilatation can then be proceeded with. 

Incisions for this purpose, and for the division of the os externum in 
cases of pinhole os and conical cervix, may need to be somewhat more 
than mere notches. Then Ktichenmeister's scissors (Fig. 89) should be 




— Scissors, uterine (Kiichenmeister's). 



used instead of ordinary scissors or bistouries. Kiichenmeister's scissors 
have a probe-pointed blade which is passed into the cervical canal, and a 
hooked blade which grips the cervix on its vaginal aspect and prevents 
its slipping, and so dispenses with the use of sharp hook or volsella 
forceps. The extent of the desired incision is regulated by the distance 
of the hooked blade from the external os uteri, as this blade is the 
cutting one. 

In all cases where a mere temporary dilatation is needed, the incision 
should be sewn up at once with wire or silk-worm gut, lest ectropion and 
chronic endocervicitis may ensue. 

Incision by means of a Paquelin's cautery, or the galvanic cautery with 
the platinum terminals brought to a dull red heat, is very efficacious in 
preventing haemorrhage ; and it may advantageously be used when it is 
desired to prevent rapid reunion of the incised cervix, as, for instance, 
when the os uteri externum has been divided for "pinhole os.'' The 
cautery, however, should never be used to incise the internal os uteri or 
the cervix high up, Avhere the branches of the uterine artery may be 
found, as, even if it prevent haemorrhage at the time, secondary haemor- 
rhage is very likely to occur ; and owing to the necessary sloughing, 
perfect asepsis at that level is very difficult to maintain. If it is desired 
to prevent closure of the incision, and the cautery has not been employed, 



292 SYSTEM OF GYNECOLOGY 

the raw surfaces should be touched with iodine liniment ; and a jjiece of 
gauze, soaked in iodised glycerine, should be kept in the cervix for some 
days, beyond the upper limit of the cut, being changed of course daily, 
and a vaginal douche given at the intervals. 

If haemorrhage be severe, it may usually be arrested by plugging the 
cervical cavity with gauze ; or the bleeding point may be touched with the 
actual cautery, though, as has just been stated, this has its disadvantages. 
If this do not arrest the bleeding, the uterine artery, or the branch going 
to the cervix, must be tied. 

In those very rare cases where, owing to the failure of a rapid dilata- 
tion, hysterotomy to the level of the os internum has been decided upon, 
it has been very strongly recommended by such authorities as Schroeder, 
Martin, and Pozzi that the uterine artery, or rather the large branch 
which enters the cervix at the base of the broad ligament, should be tied. 
This can be done by a curved needle, which should be entered precisely 
as when the artery is tied for vaginal hysterectomy, except that there is 
no need to divide any mucous membrane before passing the needle. After 
reuniting the incisions in the cervix, or at all events after the lapse of 
twelve hours, the ligatures should be removed to prevent ulceration of the 
mucous membrane where it was included in the knot. If this preliminary 
ligation of the arteries were efficiently performed, the greatest danger of 
the operation, that of death from primary haemorrhage, would be entirely 
obviated. The danger from sepsis has, of course, to be otherwise combated. 

After such an " high " operation it may be advisable to introduce a 
stem pessary, such as Meadows' glass stem, till healing is completed. 
With rest in bed and perfect antisepsis this ensures free drainage. For 
this " high" operation Kiichenmeister's scissors, which can only cut to 
the level of the vaginal vault, are not suitable ; for the cervix need not be 
cut through from its cavity into the vagina except at the os externum. 
Practically the simplest plan is to dilate the cervix partially, and then 
to incise the neck of the uterus at the desired level, and to the desired 
extent, by means of a Sims' knife (Fig. 90) set at a suitable angle, or by 




Sims' metrotome. 



a straight probe-pointed bistoury, which can be easily introduced if the 
uterus be drawn down by a volsella. 

Formerly single hysterotomes, such as Simpson's or Priestley's, v/ere 
used, but they have no advantage over a probe-pointed bistoury, which is 
far safer than the double hysterotomes, such as Greenhalgh's and its 
modifications (Savage's or Peaslee's), all of which are apt to cut more 
deeply on the side where there is less resistance, and have been the cause 
of most of the disasters to which the operation has led. 

ii. Curetting the Uterus. — Curretting was introduced by Becamier in 
1843, and was so vehemently opposed that it fell immediately into dis- 



GYNAECOLOGICAL THERAPEUTICS 293 

repute, thougli in 1850 Recamier was still advocating his curette for the 
" removal of intra-uterine fungosities," which he had discovered to be 
often the cause of obstinate metrorrhagia. In 1846 Sir Charles Locock 
described his scoop for the removal of malignant nodules, and soon after- 
wards Simon's scoop was also recommended. In 1861 C. H. E. Eouth 




uterine scoop. 



somewhat modified Eecamier's curette, and read a paper at the Obstetrical 
Society of London, giving three cases of metrorrhagia cured by its use after 
a diagnosis had been made by slow dilatation and digital exploration. In 
1866 Sims introduced his sharp curette with a malleable handle. This 



Fig. 92. — Sims' pliable curette. 

continued to be the favourite curette till about 1874, when Thomas intro- 
duced, and Munde strongly advocated, a " dull curette of flexible copper 
wire," and this was used almost universally in America for some years. 
In the same year Hegar, Kaltenbach, and Olshausen brought its use 
prominently into notice in Germany ; and in France, Trousseau, Nelaton 
(1861), Maisonneuve, and Noriat (1869) had occasionally made use of it. 
In England it was long in coming into favour, for in spite of its occasional 
use, as stated above, it was opposed at first by such men as Barnes and 
Atthill, though in 1873 the former, and somewhat later the latter, advised 
its use in serious cases. 

With such well-known gynaecologists as Courty (1866), Scanzoni 
(1861 to 1865), Thomas (up to 1871), Schroeder, and Colucci (1877) 
writing against the use of the curette, it is not surprising that very 
little progress was made ; and in spite of the recommendation of many 
strong advocates, it is probable that it would never have become so uni- 
versally employed as it is now if the era of antiseptics and of anaesthetics 
had not made it both safe and easy of execution. 

Indications for Curetting. — This operation may be used merely to 
make a diagnosis of the state of the endometrium, by scraping off a small 
piece of the mucosa for microscopic examination. For such a purpose 
a small exploratory curette can be used without previous dilatation. 
Curetting is done both for hypertrophic and atrophic endometritis. It 
is done also for cases of septic or infective endometritis, with their resulting 
purulent discharges, in order to prevent sequential tubal and periuterine 
complications from extension of the inflammation. Whether the process 
advance through the tubes, or through the lymphatics of the uterine 
tissues, the result is very serious, and a timely curetting may prevent 
such disaster. 



294 SYSTEM OF GYNAECOLOGY 

Even if the periuterine tissues be already involved, it is good practice 
to remove the infective focus in utero by an efficient curetting ; and if it 
be considered necessary to open the abdomen and deal with some serious 
condition there which has followed the endometritis, it is right to curette 
the uterus beforehand or simultaneously. In many cases the peri- 
uterine exudation, whether in tubes or peritoneum or as phlegmon in 
the cellular tissue, will disappear after a careful curetting and packing of 
the uterus with gauze to ensure free drainage ; and unless an abdominal 
section be clearly necessary, this minor operation should be first tried. 
The time will almost surely come when the practice will be to curette 
the uterus, or otherwise cure the endometritis, in all cases of tubal or 
peritoneal inflammation of uterine origin, in which there is no abscess. 

Sometimes an endometritis exists with haemorrhage as its chief 
symptom. This is usually hypertrophic and adenomatous in nature. For 
this state also curetting is indicated. 

Curetting is also needed for the removal of placental or membranous 
debris retained after labour or abortion. Such a condition is almost the 
only indication for a blunt curette, for the uterus may be very soft ; but 
in such cases the cervix is generally so patent, or so easily dilated, that 
the insertion of the finger involves no difficulty, and the piece of retained 
placenta or other matter can almost certainly be removed by the finger- 
tip alone. If, however, the discharge be septic, and especially if general 
septicaemia be setting in, a deep and thorough curetting of the whole 
endometrium is imperatively necessary if the patient's life is to be saved. 

Varieties of Curettes. — Curettes should be provided with some ar- 
rangement of the handle or shaft to prevent rotation, and to enable the 
operator to know which is the sharp and which the blunt edge of the 
end. Some curettes have a sharp loop at one end, and a blunt at 
the other ; and as these loops are on opposite faces of the shaft, the 
outside end gives sufficient indication of the direction of the intra-uterine 
end. Some curettes have loops of different sizes or curves at the two 
ends. Amongst such are Gervis' (Fig. 93), Eecamier's (Fig. 94), and 




ABNOLQ&SONSLt/NDUN 

Fig. 93. — Double uterine curette (Gervis'). 



that used at St. Bartholomew's Hospital. The first is sharp-edged, 
the second is blunted : all are excellent instruments, but it is desirable 



Fig. 94. — Eecamier's curette. 



to have at least one end of the E-ecamier's curette sharpened for deep 
curetting. For scraping away the friable tissues of a malignant growth — 
as a palliative measure, or preparatory to a radical operation — Volkmann's 



G YN^ COLO GICAL T HER APE UTICS 



295 



or Thomas' uterine scoops (Fig. 95) are better than ordinary curettes. 
Bell's dredging curette (Fig. 96) is also very useful in malignant cases, 



ARNOLII & SDKS LONDON 

Fig. 95. — Uterine scoop, or spoon saw (Thomas'). 

especially where the cervix is too friable to be grasped with the vol- 
sella forceps, and an intra-uterine diverging tenaculum has to be used. 
In such a case Bell's curette will clear a way along the uterine cavity, 
so as to admit the tenaculum, better than any other instrument. It 
is not so suitable for ordinary curetting unless the uterine cavity be 
normally regular in outline ; though much may be done, by outside supra- 




FiG. 96. —Dredging curette (Beirs). 



pubic pressure, to bring the different parts of the endometrium in contact 
with the instrument, which has other advantages, and can be constructed 
with a hollow shaft for flushing purposes. Jessett's watch-spring dredg- 
ing curette is more dangerous, but is otherwise on the same lines. Both 
these instruments leave too much to chance, and most operators would 
therefore prefer an ordinary looped curette, which is more generally 
useful. 

Flushing curettes — that is, curettes with the shaft hollowed out from 
the end of the handle to the space within the loop of the scraping end — - 
are very useful, and may be made like Duke's, with the shaft only partly 




Fig. 97. — Uterine flushing curette (Auvard's). 

hollowed ; or like Auvard's (Fig. 97), wdth a i^lace on the shaft in which 
to dip the pulp of the index finger to secure steadiness ; or like E-outh's 




Fig. 98. — Eouth's flushing curette. 



(Fig. 98), which is longer in the shaft, has the tubing attached to the 
extreme end of the handle, and, half-way along the shaft, has a flat plate 



296 SYSTEM OF GYNECOLOGY 

to lie in the palm of the hand to steady the instrument and prevent 
rotation. 

The Operation of Curetting. — It may be assumed that dilatation has 
been performed, that sufficient exploration of the uterus, by sound, ex- 
ploratory scraping, or insertion of the finger, has been made, and that 
curetting is indicated. 

The patient should be in the lithotomy position, both to facilitate the 
operation and to permit a perfect irrigation. The cervix is steadied and 
lowered as in rapid dilatation, and the largest-sized curette which will 
readily enter is passed up to the fundus, and then withdrawn with the 
sharp edge against the mucosa. This is repeated all over the intra- 
uterine surface. Special care is taken at the two cornua, as clumps of 
hypertrophic tissue are apt to collect there ; to get at them it may be 
necessary to use a smaller curette, or one with the end set at a different 
angle. The cervix also should be subsequently curetted. In curetting, 
pressure with the sharp end should be firm and equal ; and in going over 
the surface again to make sure (if possible) that all of the mucosa has 
been removed, it will be noted that if the curette cause a grating feeling 
or sound, it indicates that the mucosa has already been removed ; but 
if no such sensation is produced, the lining membrane is still intact at 
that spot, and needs further attention. 

After Treatment. — The uterus should be washed out with an antisep- 
tic douche at about 118° F., if no flushing curette has been used ; and 
then its rawed surface should be painted freely with iodine liniment, 
carried up through a speculum on a probe armed with plenty of wool. 
In any case where sceptic or infective endometritis exists, the uterus 
should then be packed with iodoform gauze to encourage free drainage ; 
if further intra-uterine treatment be indicated, the gauze, which should 
be removed in twelve hours, should be replaced, and the uterus kept pat- 
ent. If there should be severe haemorrhage this packing should also be 
resorted to, done however more tightly, with a firm vaginal tampon below. 
In this latter case the uterine tampon may be left in for twenty-four 
hours. In most cases antiseptic douches are advisable for the first week, 
after which time the patient may get up and may resume her ordinary 
duties in a fortnight. 

iii. Alternatives to Curetting. — Excluding serious operation like 
hysterectomy, always unjustifiable in cases where curetting is an 
alternative, these cases of endometritis must either be treated pal- 
liatively by curetting or by some escharotic. 

Minor palliative methods have been described under the heads of 
intra-uterine medication, and dilatation by gauze-packing, and need not 
here be again referred to, except to say that, as stated on page 276, some 
of the mild and uncomplicated cases of endometritis will yield to them. 

Treatment by escharotics, such as chloride of zinc, nitric acid, or 
electricity with strong currents, involves the formation of extensive 
sloughs, the depth of which cannot be regulated. Such a slough is itself 
a danger, and, as the surface of repair which is left has very little 



G YN^ COL O GICAL THERAPE UTICS 



297 



protective epithelium to defend it against the passage of pathogenetic 
germs, the slough is thrown off by suppuration, and an atrophic endo- 
metritis results. Curetting, therefore, preceded by dilatation and followed 
by gauze-packing, is by far the safest method of treating these cases ; 
and when repair begins, the uterus is relieved of the septic process. 
As Baldy says, "new leucocytes and plasma cells are not forced to exercise 
their phagocytic properties by battling with pathogenic germs, but the 
plasma cells have a healthy pabulum, and devote their entire energy to 
the work of regeneration, which is not merely non-suppurative repair, 
but is histological growth." 

Reproduction of the Endometrium. — After a thoroughly antiseptic 
curetting the endometrium is reproduced in about two months, that is, 
between the second and third catamenial periods following the operation. 
After destruction of the endometrium by acids or other escharotics. 







-f^m 



V 



V 1/ V d 

Fig. 99. — Vertical section three moiuhs after curetting, a, Epithelium; l>, new-formed glands; c, 
connective tissue ; (?, muscular tissue of the uterine walls ; v v, blood-vessels. (From Baldy's TexU 
Book of Oynoicology by kind permission of the editor of the Nouv. Archiv. d'obsiei. etde gynecol.) 



suppuration ensues, with the formation and separation of a slough ; and 
the endometrium is very imperfectly re-formed after the lapse of three or 
four months. In both cases the mucous membrane is re-formed mainly 
from the cells of the connective tissue which covers the muscle layers of 
the uterus ; but there is an essential difference in the new membrane 
formed under these circumstances. After chloride of zinc paste has been 
used the connective tissue layer is much injured, and may be destroyed ; 
for the action of this caustic is very uncertain, and may, as is desired by 
those who use this agent for cancer of the uterine body, lead to destruc- 
tion of the muscle also. 

After curetting, the connective tissue is rarely injured ; and in addition 
to this, it is more than probable that the most skilful operator would 
almost invariably leave islets of mucosa from the edges of which new 
epithelium would spring. The bases of many of the uterine glands also 
dip down so far, some even into the muscular layer, that they certainly 



298 



SYSTEM OF GYNECOLOGY 



would not be reached even with a sharp curette, and they may therefore 
be additional sources of epithelial regeneration. 

Sections of a uterus taken three months after curetting show 
(Fig. 99) under the microscope healthy ciliated epithelium, with newly 
formed glands dipping down into the connective tissue, which is richly 




Fig. 100. — Vertical section of the uterine mucous membrane fifty-five days after the application of a 
caustic. «, Epithelium; &, connective tissue; cc, section of the glands which have undergone 
cystic degeneration ; d, tubular glands enormously dilated ; m, muscular tissue of the uterine 
wall. (From Baldy's Text-Book of Gyncecology by kind permission of the editor of the Nouv. 
Archiv. cfobstet. et de gynecol.) 

supplied with blood-vessels. In other words, the endometrium is ab- 
solutely normal. This happy result can only be expected when no fresh 
infection of the parts has meanwhile occurred, and when suppuration has 
been absent. On the other hand, microscopical sections of the uterus 
following the use of chloride of zinc (Fig. 100) show an imperfect non- 
ciliated epithelium, greatly exaggerated connective tissue, and a few 
partially formed glands, which do not open on to the surface of the 
endometrium, but are mostly distended into small cysts from blocking 



GYNECOLOGICAL TILERAPEUTICS 299 

of their surface orifices. The condition is, in fact, one of chronic inter- 
stitial endometritis, with its accompanying atrophy of the epithelial 
elements. 

Pregnancy after the use of an escharotic, used as assumed above, is 
very rare. After curetting it is, however, very common, and indeed, in 
suitable cases, this operation has cured many women of an obstinate 
sterility. Heinricius collected statistics of this, and showed that out 
of 52 patients, whose history after curetting he was able to learn, 16, 
or 30 per cent, conceived ; he states that pregnancy commenced in two 
cases five weeks, and in one case eight weeks after the operation. 

Amand Kouth. 

REFERENCES 

1. Allbutt, T. Clifford. Goulstonian Lectures, 1884. — 2. Auvard, A. Traite 
Pratiqiie de Gynxc. 1894.-3. Ballance and Edmunds. Treat, on the Ligation of 
Arteries, 1891, pp. 259 and 271.— 4. Baldy, J. M. Text-Book of Gijnsec. 1894, p. 227. 

— 5. Barnes, Robert. Diseases of Wotnen, etc. — 6. Braithwaite, James. Brit. 
Med. Jour. June 29, 1895, p. 1438. — 7. Champneys, F. H. 3red. Soc. Trails, vol. xv. 
1892, p. 374.-8. Dickenson, Dr. R. L. Aiuer. Jour, of Obstet. Jan. 1895.-9. Doleris. 
Nouv. Archiv. d'obstet. et de gyn. vol. vi. p. 401. — 10. Ferria. Gazetta Medica di 
Torino, Dec. 13, 1894,-11. Goodell, William. Les.wns in Gynxc. p. 98; Med. 
Gynxc. 1895.-12. Head, Henry. Brain, vol. xvl. 1893, pp. 1 to 134.-13. Hein- 
ricius. Gynxc. og Obstet. Med. vol. vi. No. iii. p. 134. — 14. Herman, G. E. Obstet. 
Soc. Trans, vol. xxxvi. 1894, p. 250.-15. Lewers, A. H. N. Lancet, 1891, p. 1119.— 
16. Malcolm, J. D. Med. Chir. Trans, vol. Ixxi. 1888, p. 43. — 17. Martin, A. 
Path, und Ther. der Frauenkr. 1887, p. 26.-18. More, Madden. Brit. Med. Jour. 
1884, vol. ii. p. 1068.— 19. Olshausen. Cent, fdr Gynxc. July 1888.-20. Pesser, 
De. Annal.de Maladies des Org. Gen. -ui-in. Jan. ISM. — 21. Phillips, John. Lane. 
1887, vol. ii. p. 507. — 22. Pozzi, S. (Syd. Soc.) Treat, on Gynxc. 1888, pp. 31 and 141. 

— 23. Rousing, Theodore, i/osp. ricZ-nrZe,Feb.7, 1894. — 24. Routh, Amand. "Rapid 
Dilat. of Uterus," Med. Soc. Trans. 1892, p. 347. — 25. Routh, C. H. F. " Conserv. Surg, 
in Pelv. Dis.," Med. Press and Circ. May 1894. — 26. Ibid. "Cases of Menorrhag. 
treated by the Gouge," Obstet. Soc. Trans, vol. ii. 1860, p. 117.-27. Schroeder. 
Zeitsch. f. Geb. und Gynak. 1881, vol. vi. p. 29.-28. Schultze, B. S. Displace- 
moits of Uterus (trans, by Dr. Macan), p. 222.-29. Sloan, C. F., of Ayr. Glasg. Med. 
Jour. vol. x. 1862, p. 281.-30. Tait, Lawson. Dis. of Ovaries, 4th ed. p. 309; 
Brit. Med. Jour. May 15, 1886, p. 921.-31. Thomson, H. F., of Dorpat. Cent. f. 
Gynxc. vol. xiii. 1889, p. 409.-32. Trelat. Annal. de gyn. et d'obstet. Paris, May 
1891. _33. Treves, F. Lettsom : Lect. Med. Soc. Trans, vol. xvii, 1894,-34, Vulliet. 
Nouv. Archiv. d'obstet. et de gyn. 1886, p, 693.-35, Ibid. Le(}ons de gyn. operatoire, 
1890, p. 78,-36. Wright, A, E, "Methods of Increasing the Coagulability of the 
Blood," Brit. Med. Jour. July 14, 1894. 

A. R. , 



300 SYSTEM OF GYNECOLOGY 



THE ELECTRICAL TREATMENT OE DISEASES 
OE WOMEN 

The successful employment of electricity in tlie treatment of the diseases 
of women is of very recent date. General attention was drawn to it in 
1886, when Dr. Georges Apostoli of Paris published the results of five 
years' experience of its use in this class of cases, and at the same time 
gave a full account of the method by which he carried it out. That the 
method was new admits of no discussion. No doubt many attempts had 
been made in previous years to utilise electric energy in some form or 
other for this purpose ; but the knowledge of these attempts was of value 
to Apostoli only in so far as it showed him what to avoid. 

The limits of this article do not permit me to review the efforts of 
earlier workers in this field ; and, indeed, but little purpose would be 
served by such a review. We may take it that the present position of 
electricity in gynaecology is simply this, that it consists of the application 
of Apostoli's methods with such slight modification of details as has been 
suggested by the experience of workers following on his lines. 

I purpose in the following pages to consider this subject under these 
heads : — 1. The armamentarium, or instrumental equipment, required in 
gynaecological electro-therapeutics. 2. The modes of making the applica- 
tions. 3. The modes of action of the current. 4. The diseased con- 
ditions in women which can be treated by electricity, and an account of 
the modes of procedure in each. 

I. The Armamentarium. — The suitable instrumental equipment of 
the gynsecologist for electrical treatment is a matter of the first importance, 
and deserves careful consideration. Much of the disappointment and 
failure which have ensued on attempts to carry out electrical treatment 
with currents of relatively considerable strength have resulted from the 
unsuitable nature or mismanagement of the battery and other instru- 
mental means employed. It is essential, then, that the apparatus should 
be suitable and well cared for, otherwise vexation and disappointment 
are inevitable. It is sometimes forgotten that a battery is capable of 
giving out only an amount of energy corresponding to its size. When 
an ordinary portable " constant current " battery of thirty or forty small 
cells is found exhausted after a small number of sittings the practitioner 
is annoyed, and this method of treatment is called impracticable. But 
the failure is due to the employment of an unsuitable and inadequate 
source of energy. 

We shall consider first, then, the most convenient and suitable form of 
battery. The current from the electric lighting mains of a continuous 
low pressure supply is the most convenient source of energy for the 
purpose in view ; but this source is not as yet generally available. Con- 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 301 



sequently the majority of practitioners must fall back upoD some form of 
primary battery. The form of battery will depend on whether the 
treatment is to be carried out in the physician's rooms or at the patient's 
residence ; in other words, whether the patient is to come to the battery, 
or the battery is to go to the patient. There can be no donbt that the 
former arrangement is much the more satisfactory ; it permits the use 
of a large-celled stationary battery, and avoids the inevitable incon- 
venience associated with the carriage of a portable one. I shall con- 
sider first the most convenient kind of stationary battery. 

Experience has shown that some form of Leclanche cell is the most 
suitable. The simplicity of its construction and the harmless fluid used 
are matters of great advantage. Any good form of cell, such as is 
used for electrical bells or telegraph Avork, will suffice. An excellent 
type of cell is sold by Mr. K. Schall (Fig. 101). The carbon element is 
a cylinder about 2 inches in diameter, pierced 
by a central channel 1^ inch in diameter. 
The mouth of the glass jar is surrounded by 
an indiarrubber collar, which supports a lead 
flange attached to the carbon cylinder; the 
carbon thus hangs in the liquid, being half 
an inch clear of the bottom of the jar. This 
space prevents the formation of crystals on 
the lower end of the carbon. In the central 
channel hangs the zinc rod ; this rod is attached 
to a china disc which rests on the top of the 
carbon cylinder in such a way as to prevent 
its shifting or coming in contact with the 
carbon. An india-rubber ring is slipped over 
the lower end of the zinc rod, which effectually 
prevents its touching the carbon cylinder at 
that point. The cell is thus of a simple and workmanlike construction, 
and has a very low internal resistance — a matter of some consequence. 
Whatever kind of cell is used it should be of at least a quart capacity. 
From thirty to forty of such cells will be required. 

The efficiency and length of life of such a battery will depend largely 
on the manner in which it is charged and set up; and the following 
instructions may be found of use : — The glass jars after being unpacked 
should be wiped inside and out with a dry cloth so as carefully to free 
them from straw and dust. Care should be taken not to damage in any 
way the coating of paraffin round the outer edge ; the object of the 
paraffin is to prevent " creeping," and if it should be deficient or cracked 
it should be repaired by brushing a little melted paraffin over it. 
The jar should then be rather more than half filled with a saturated 
solution of sal ammoniac. The salt used should be nearly pure ; the 
common or commercial form gives very unsatisfactory results. The 
rubber collars are then to be fitted, and the carbon cylinders put in. 




Fig. 101. —Leclanche cell. 



Great care should be taken that the outside of the jars be not wetted by 



302 SYSTEM OF GYNECOLOGY 

sparking of the fluid. The introduction of the carbon will raise the fluid 
within 2 inches of the shoulder of the cell. The cell should be allowed 
to stand for twenty-four hours, at the end of which time the fluid will 
have sunk a little owing to the absorption of some of it by the porous 
carbon. The cells are now to be filled with plain water to a level of one 
inch below the shoulder ; this will reduce the saturation somewhat, and 
avoid the risk of any part of the salt crystallising out. If the fluid used 
be fully saturated this change is apt to occur in cold weather, and crystals, 
forming in the space round the zinc rod, may ultimately make a bridge 
between the elements, an accident which will rapidly destroy the cell. 
The zinc rods may then be placed in position, and the cells arranged in 
their permanent places. The most convenient place is a dry roomy cup- 
board, the shelves of which should be varnished or covered with thick 
brown glazed paper. If a cupboard be not available, stout shelves must 
be provided. If forty cells are employed they should be arranged in two 
sets of twenty cells each on two shelves, each set consisting of two rows 
of ten cells. A clear inch should be allowed between each cell, and two 
or three between each row. In this way any cell can readily be removed 
for any purpose, and the cells periodically tested as to efficiency. Before 
being placed on the shelf each cell must be carefully dried from any stray 
drops of solution or moisture which may have been deposited on it. This 
precaution should not be omitted, as the efficiency and durability of the 
battery greatly depend on keeping the cells thoroughly dry on their 
external surface. The cells may now be connected up ; the carbon of 
each should be joined to the zinc of the next by a piece of clean No. 18 
copper wire, care being taken that the binding screws are well screwed 
up and the wires firmly held by them. This will leave a free carbon and 
a free zinc at the end of the battery ; from these, pieces of insulated wire 
should run to a couple of stout binding screws fixed to one of the shelves. 
The binding screw connected with the last carbon will be the positive, and 
that connected with the last zinc will be the negative pole of the battery. 
A battery consisting, say, of forty cells, if tested by a volt meter, should 
give an electro-motive force of about 58 volts ; and as the resistance of 
each cell, when in good condition, is about 0-5 ohm, the total resistance 
of the battery will be about 20 ohms. On short circuit, then, the battery 
will give, for a short time, nearly 2-5 amperes. With a good abdominal 
electrode properly applied, and a sound in the uterus, the resistance of 
the human body averages about 150 ohms ; thus the battery will be 
capable of transmitting a current of about one-third of an ampere through 
the tissues of the patient. This is more than sufficient for all ordinary 
purposes ; but as the electro-motive force tends to fall and the internal 
resistance to rise, it is well to be provided at the outset with a certain 
amount of surplus energy. If properly used and cared for, such a battery 
will prove efficient for a very long time. The following matters must 
be attended to it disappointment is to be avoided: — 1st, The battery 
should not be allowed to remain idle for long intervals : if it happen 
not to be used for a few weeks at a time, crystals tend to form on 



THE ELECTRICAL TREATMENT OE DISEASES OF WOMEN 303 

the zincs, and when next examined the internal resistance will be found 
greatly increased. If the battery is not to be used for a week or two, the 
terminlas ought to be connected to a resistance, and a current of 50 or 60 
milliamperes allowed to flow for five or six minutes at least once a fort- 
night. Attention to this will do much to prolong the life of a battery ; 
nothing is worse for it than long periods of idleness. 2nd, From time to 
time the evaporation from the vessels should be made good by the addition 
of a little water. 3rd, Once a month each cell should be tested with a 
galvanometer to see that it is giving its proper quota of energy. This 
can be done without disconnecting the cells, by having two stiff copper 
wires attached to flexible leads connected with the galvanometer, with 
which the terminals of each cell may be touched. If any cell gives a 
smaller deflection than it should do, it should be removed and examined 
for the cause of the defect. This may be creeping of the fluid over the 
edge of the cell, or accidental contact of the plates in the fluid. The 
defect should be rectified, and the cell tested and returned to its place ; 
but the battery may, of course, be used without the defective cell if those 




Fig. 102. —Carbon rh« 

on each side of it be connected by a piece of stout copper wire. 4th, 
Any fluid accidentally spilt on or about the cells should be carefully 
dried up at once. 

When such a battery has been in use for two or three years it will 
show signs of exhaustion ; it should then be taken apart, the solution 
replaced by a fresh quantity, and the zincs reamalgamated. Any of the 
latter which are much worn should be replaced by new ones : this 
may be done at the cost of a few pence for each rod. With careful and 
regular use, and an overhaul now and then, a battery of this sort may 
remain in good working order for an indefinite time. 

Tlie Current Regulator. — For the control of this or any other battery 
some form of current regulator is necessary. For portable batteries the 
cell collector is probably the most convenient means ; but for a fixed 
installation such an arrangement is impracticable. The regulation in this 
case is best effected by some form of rheostat or adjustable resistance. 
The most convenient form of rheostat at present available is one made 
of filaments or thin rods of carbon, which can be cut out or introduced 
into the circuit gradually by means of sliding metal pieces (Fig. 102). 
This arrangement permits of increase or diminution of the current to any 
extent without the least interruption or shock — a matter of essential 
consequence in the use of strong currents. Four of these rheostats, 



304 



SYSTEM OF GYNECOLOGY 



mounted in series, will be found a convenient combination ; and the 
following approximate values will be suitable : No. 1 of 200 ohms ; 
No. 2 of 1000 ohms ; No. 3 of 10,000 ohms ; No. 4 of 100,000 ohms. 
With such a combination inserted into the circuit between the battery 
and the patient about 2 milliamperes of current will pass, so that the 
patient may be connected to the terminals w^ithout any appreciable 
shock. 

Liquid rheostats have been devised for this purpose ; but, although 
they are cheaper than those just described, they are very apt to get out 
of order, and seldom can be regulated through the necessary range. 
They are thus very unsatisfactory. E-heostats consisting of graduated 
coils of wire, which can be switched in or out of the circuit, have been 
employed ; they are costly, and they are also imsatisfactory, because the 
passage from one coil to another means a more or less abrupt drop in the 
resistance with a corresponding abrupt rise in the current. The patient 
is thus subjected to a series of unpleasant shocks, and this defect alone 
is enough to condemn them. 

The Galvanometer. — A galvanometer calibrated to read directly in 
milliamperes (hence termed a milliampere meter) is an essential part 
of the apparatus. These are now comparatively cheap, and are so 
constructed as to be readily portable. Probably the most con- 
venient form is that made by Dr. Edelmann of Munich. These 
instruments are fairly accurate, wear well, and can be readily transported 
if need be. The best form is that in which the needle is suspended by a 
silk fibre ; for, however satisfactory the pivoted form of magnet may be 
at first, it becomes less so by use on account of the blunting of the pivot 
by continued swinging. Edelmann's instruments are nearly dead beat, 
that is, after the passage of a current the needle assumes its proper 

position, with one or two small oscilla- 
tions only. This is an undoubted 
advantage, as the current can be 
quickly adjusted and read off. 

A convenient instrument sold 
by Mr. Schall is shown in Fig. 103. 
The dial of this instrument is divided 
into fifty divisions : with both shunts 
withdrawn, each division represents 
0-1 m.a. ; with the 10 shunt screwed 
in, each division represents 1 m.a. ; 
with the 100 shunt screwed in, each 
division indicates 10 m.a. : thus the 
total range is from 04 m.a. to 500 
m.a. For those who desire an in- 
instrument of the highest class, the milliampere meter, made specially for 
physicians' use by the Weston Electrical Company of America, may be 
strongly recommended (Fig. 104). These instruments are beautifully 
constructed, accurately adjusted, and absolutely dead beat. Moreover 




Fig. 103. — Edelmann galvanometer. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 305 



they are quite portable, require no levelling, and seem to undergo no 
change by continued use ; they are, however, somewhat costly. They 
may be obtained from Elliott Brothers, of 
101 St. Martin's Lane. 

When any of the swinging magnet 
galvanometers are used they must be set up 
on a level surface or adjusted by levelling 
screws ; the instrument must then be so 
turned that the needle points to zero on the 
scale. These galvanometers should be kept 
as far away as possible from anything made 
of iron, such as a grate, stove, or iron 
bracket. With the Weston instrument 




Fig. 104. - 



Weston inilliauipere meter. 

such a precaution is unnecessary ; they may be set down on any 
surface, and the vicinity of iron does not influence them. 

Connecting icires must be provided to convey the current from the 
battery to the patient. These may conveniently be made of copper wire 
(No. 18) insulated with india-rubber covered with cotton or silk ; or they 
maybe made of the stranded flexible cord used for pendant electric lights. 
They should be at least 4 feet in length, and of different colours, so that 
they can be readily distinguished. 

Electrodes. — By electrodes we mean the special appliances by which 
we bring the current into contact with the patient. In gynaecological 
therapeutics we distinguish them by the terms internal and external, 
according as they are to be introduced into the interior of the body or 
applied to the skin. They are of course electrically distinguished by the 
pole with which they are connected. 

Internal electrodes may be introduced into the uterus or simply into 
the vagina. The intra-uterine electrode usually takes the form of a sound. 
The most generally convenient form is one made like an ordinary uterine 
sound, the three or four inches at the point being made of platinum (Fig. 
105). To the handle is fixed a binding screw for attachment of the flexible 




Fig. 105. — Intra-uterine electrode. 



conductor. A gum elastic or celluloid sheath slides on the sound and 
can be clamped at any point, so as to expose more or less of the platinum 
end. In this way a greater or a smaller part of the uterine surface is 
brought directly in contact with the metallic surface of the electrode, 
and so with the current. In certain cases, as we shall see later, the best 
results are obtained by limiting the area of contact to a considerable 
extent. For this purpose Apostoli uses electrodes having carbon ends 
about 0-75 inch in length (Fig. 106). By moving this along the uterine 

X 



-ioG 



SYSTEM OF GYNECOLOGY 



canal successive portions may be treated at will. These electrodes are, 
however, straight and often difficult if not impossible to introduce. I 



Fig. lOG. — Apostoli's carbon electrode. 

have used a sound which is about the diameter of a No. 10 bougie (Fig. 
107). This is insulated up to half an inch from the point. This half inch 
consists of platinum of the same diameter as the rest of the sound, and 
is screwed to a copper rod passing down to the handle and ending in a 
binding screw. The position of the platinum tip can be regulated and 
adjusted in the uterus by means of the sliding collar which is connected 
to a gauge on the handle. This electrode can be readily passed into any 
uterus the cervical canal of which is sufficiently wide to admit it ; and in 
the cases where the treatment is specially useful this condition is generally 




Fig. 107. — Adjustable platinum electrode. 

present. In cases where the cervix is so displaced by a fibroid that it can- 
not be reached, or incase it be impossible to introduce the sounds described, 
it will be necessary to puncture the tumour at its most prominent point, so 
as to carry the current directly into its substance ; for this purpose some 
form of pointed electrode must be used. Apostoli recommends the use 
of an instrument constructed like the ordinary sound electrode, but ending 
in a sharp point ; this is inserted into the mass for about 1 cm., and the 
sheath is then pushed up to the vaginal roof. The objection to this 
method is that the tissue of the roof is electrolysed, and an open sinus 
is formed leading from the vagina to the deepest part of the puncture. 
This lesion is obviously not free from risk of septic infection passing from 
the vagina into the tissue of the tumour. A better plan is to use a needle 
similar to that employed for the electrolysis of aneurysms or nsevi, but 
of course much larger (Fig. 108). The rubber insulation of this stops 



Fig. 108. — Electrode for puncture. 



about ^ inch from the point, which is of course sharp ; thus the needle 
can be plunged well into the tumour, the rubber sheath passing through 
the vaginal roof, which is thus merely punctured, not electrolysed; and 
on the withdrawal of the needle the puncture closes up again. The 
electrolysis is thus confined to the tissue of the tumour. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 307 

Vaginal electrodes may be made of plain metal bulbs carried on an 
insulated stem, or the bulb may be covered by a piece of cotton soaked 
in salt solution (Fig. 109). 

TVie External Electrode. — The purpose of the external electrode is to 
distribute the current, as it enters or leaves the body, over as large an 
area of skin surface as practicable. The result is so to diminish the 
cutaneous resistance as to permit the passage of a current of considerable 
strength by means of a moderate electro-motive force ; and this without 
the production of much pain. The main points in the selection of the 
electrode then are these : 1st, it must be a good conductor ; 2nd, it must 
cover as much of the abdomen as practicable ; and, 3rd, it must make good 
contact with the moistened skin. 




Fig. 109. — Vag-inal electrodes. 



The external electrode first recommended l)y Apostoli, and still 
used by him and others, is made of moistened sculptor's clay rolled 
into a suitable thickness, and sufficiently large to cover the greater part 
of the anterior abdominal wall. The clay is moistened with water and 
a little glycerine, and rolled to a stiff consistence with a rolling pin. It 
should be about half an inch in thickness, and about 10 by 8 inches in 
area. The clay should then be placed on a piece of muslin large enough 
to extend about 3 inches beyond the electrode all round ; by this edge 
the electrode can be readily lifted and placed on the abdomen, the 
muslin being next the skin. A thin sheet of lead, about 6 inches 
square, is then placed on the clay and pressed into it, and to this one 
of the connecting cords is attached. The undoubted advantage of this 
electrode is that it forms an excellent contact with the skin, moulding 
itself to all the elevations and hollows, and so reducing the resistance 
to a minimum. It is certainly easier to transmit heavy currents by this 
electrode than by any other. Its disadvantages are, that in spite of every 
care it is troublesome to make ready, and apt to be very dirty ; and 
as it is most effective when applied cold, it is unpleasant to the pa- 
tient. If warmed it is apt to become dry on the surface, and thus to 
lose its efficiency. There are, however, a number of external electrodes 
which make good substitutes for the clay ; and experience has shown 
that in most cases it is not necessary to employ the very high currents 
first recommended which can certainly be best transmitted by means of 
the clay. For most cases a simpler and pleasanter form of electrode 



3o8 SYSTEM OF GYNECOLOGY 

may be employed: thus a double fold of thick flannel, about 10 inches 
square, soaked in a warm solution of salt in water, and laid carefully on 
the abdomen, makes a good contact ; upon this a plate of lead or zinc, 
about 4 inches square, should be laid, and connected by a binding screw 
with one of the connecting cords. A piece of mackintosh laid on the 
whole will prevent the moisture from escaping or wetting the dress. 
Again, a piece of sheet lead of sufficient size may be thickly padded 
with cotton wool on one side ; when this is soaked in salt water it 
makes a good conductor, and will make close contact with the skin. 

One of the best of these electrodes, according to my own experi- 
ence, is supplied by Mr. Coxeter. It is made of a sheet of brass wire 
cloth on which a composition, consisting mainly of gelatine, has been 
poured. The surface of the gelatine is made very smooth. This is 
sponged over with plain warm water until it is slightly softened, and it 
is then carefully laid on the abdomen: if pressed down all round it 
will adhere slightly to the skin, making very intimate contact, and offering 
slight resistance. Currents of considerable intensity — 150 to 200 m.a. 
— may be transmitted by means of this electrode ; and if carefully 
made so as to be free from air spaces, it will last for a long time. When 
it has become rough on the surface it may be smoothed by means of a 
hot knife passed carefully over it. Several other materials have been 
recommended, but one or other of these described will be found sufficient 
for all purposes. 

With such an equipment the gynaecologist is in a position to make 
all the applications of the continuous current which experience has shown 
to be of practical use. It is, of course, presumed that the patients are 
to attend for treatment ; and there can be no doubt that the best results 
are obtained when this can be arranged. The stationary battery can 
with reasonable care be relied on to do its work in a way which never 
can be expected from any form of portable battery, all of which are 
liable to disorganisation from a variety of conditions which cannot al- 
ways be foreseen or provided against. 

Nevertheless it may be convenient or necessary on occasion to con- 
duct the treatment by electricity at the residence of a patient ; in this 
case, of course, a portable battery must be employed. Hence it will be 
advisable to say a word or two about the most suitable instrument for 
this purpose. A battery of thirty or forty cells will be required. The 
Leclanche element is again the most suitable. A very convenient 
battery is made by Schall (Fig. 110). This contains the requisite num- 
ber of elements, and is fitted with a double collector, by which not only 
can the cells be introduced into the circuit one by one, but any set or 
group of cells can be selected, so that the battery can be evenly and thus 
economically used. In place of the " collector " a rheostat may be used 
similar to the one already described. This will be found convenient, but 
it is more costly. A galvanometer is fitted to this instrument so that 
nothing in addition but the electrodes is required. Such a battery is not 
unduly heavy — about 38 lbs. — and is thus fairly portable. It is, how- 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 309 

ever, liable to accident by careless use, and if violently jolted may be 
damaged by the cracking of a cell. If kept in good order it may give 
from sixty to seventy applications of average strength and duration, 
after which its electro-motive force will begin to fall and its internal 
resistance to rise, so that the available current will be greatly reduced. 
In these batteries the cells should be tested from time to time, and any 
defective one at once removed and replaced by another until it can be 
repaired. For this reason it is advisable to have a few spare cells at hand. 




Fig. 110. — Portable battery with collector and galvanometer. 

Induced, alternating, or -'faradic^' currents are frequently employed in 
gynsecolog}^, and for the production of these many convenient appliances 
are available. The most convenient portable faradic apparatus is that 
knoAvn as Spamer's ; the whole apparatus is contained in a box 5 inches 
square, and includes a bichromate cell and coil with the necessary con- 
nections. For use in the consulting room Mr. Coxeter and Mr. Schall 
both supply very excellent coils of the Dubois Eeymond pattern, which 
can be excited by two large Leclanche cells, or by a bichromate cell. 
In these the rate of iiiterruption can be widely varied, and the strength 
adjusted by the sliding of the secondary on or away from the primary. 
It is advisable in these last patterns to have two secondary coils, one of 
many turns of thin wire, say 5000, and the other of a smaller number 



3IO 



SYSTEM OF GYNECOLOGY 




^i'-iiiiiiii^^^^^MiiiiSlililiiiiiiii^siiiiiiiiiiiSiiiiiilii 
Fig. 111. — Spamer's induction coil. 




Fig. 112. — Sledge induction coil. 

of turns of thick wire, say 200. The electro-motive force of the two 
differs in proportion to the turns on the coil. Convenient forms of such 
instruments are shown in Fiq-s. Ill and 112. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 311 

It is now necessary to consider tlie loay in which the pieces ofapparatits 
described above are to be connected up for use. We shall presume that a 
stationary battery of the kind described is to be employed. A level 
table or shelf must be provided close to the couch on which the patient 
is to lie. The rheostat and galvanometer are arranged on this shelf or 
table, and an insulated flexible wire is to be brought from, say, the 
positive terminal, and firmly connected to one of the binding screws of 
the rheostat. A similar Avire is brought from the negative terminal of 




Fig. 113. — Eepulator switchboard for continuous and induced currents. 



the battery and connected to one of the binding screws of the galva- 
nometer. The slides of the rheostat must be so arranged that the full 
resistance is in circuit, while the galvanometer must be so adjusted that 
the needle points to zero. If it is proposed to use a current of more 
than 50 m.a. the 100 shunt must be screwed in ; if less than 50 m.a. 
the 100 shunt must be withdrawn and the 10 shunt screwed in. The 
flexible connecting cords must then be attached to the rheostat and the 
galvanometer, the one attached to the former being now the positive 
pole, and that to the latter being the negative. These are now ready to 
be attached to the respective electrodes, after the latter have been 
adapted to the patient. 



312 



SYSTEM OF GYNECOLOGY 



When a number of patients are under regular treatment it is advis- 
able and most convenient to have the various instruments permanently 
connected up on a kind of switch board ; so that, after applying the elec- 
trodes to the patient, it is only necessary to connect the electrodes to the 
conducting cords and turn on the current. Such an arrangement is 
shown in the accompanying figure, which illustrates the switch board 
(Fig. 113) employed by myself for a number of years, and which I have 
found exceedingly convenient. 

As already mentioned, there is no doubt that the most convenient 
source of energy for electrical treatment is the lighting mains of a con- 
tinuous low pressure supply. There are two ways in which the current 
strength may be regulated : 1st, the patient may be put in the main 
circuit with a resistance interpolated, sufficient to reduce the current, so 
that not more than one or two m.a. will pass. One hundred thousand 
ohms will be required to do this. The switch board shown in the pre- 
ceding figure will serve the purpose very well, and another made by 

Schall is shown in Fig. 114. The 
objection to this method is that 
at the moment of making and 
also at breaking contact the 
patient experiences a somewhat 
sharp and disagreeable shock, 
owing to the high voltage ; 2nd, 
the patient may be in a shunt 
circuit. This arrangement is 
shown diagrammatically in Fig. 
115. The current from the main 
passes to the resistance E. The 
patient is in a shunt circuit con- 
nected with one end of the resist- 
ance and the slider M. By shift- 
ing the position of the latter the 
voltage of this shunt circuit can 
be raised from 0-1 volt to 50 or 
60 volts ; and in this way, with- 
out shock or interruption of 
any kind, the current can be 
varied from a fraction of a 
milliampere to the required 
strength. A convenient switch 
board fitted on this principle 
by Schall is shown in Fig. 116. 
In all cases where current is 
taken from the mains an eight 
or sixteen candle power lamp should be interpolated. This acts as a 
safety resistance, and prevents the passage of more than 250 m.a. in 
the former case, or 500 m.a. in the latter. 




Fig. 114, — Switch board for regulating lightin 
rents by means of resistances. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 313 



II. Mode of Making the Applications. — We may now consider the 
details of the procedure for administration of the current. Careful atten- 




FiG. 115. —Diagram of switch board for regulating lighting currents by means of shunt, 

tion to these details is essential to success and to the avoidance of serious 

accidents. It must be carefully kept in mind that the use of currents of 

100 m.a. and upwards is not free from 

danger, and that serious mischief may 

result from carelessness in their use. 

The patient should be directed before 

attending to take a vaginal douche of 

warm (105° F.) water made antiseptic 

by carbolic acid 1-40. This should be 

copious, two quarts at least. On arrival 

she should remove her ordinary clothes, 

and put on a night and a dressing 

gown, the latter made so as to open 

completely down the front. She wears 

her stockings of course, and should 

also put on warm slippers. She should 

now lie down on the couch, which 

should be moderately high and firm, 

and should be covered with a rug or 

blanket. In cold weather her feet 

should rest on a hot water bottle. 

Let us suppose that a continuous 
current is to be applied to the interior 
of the uterus for the treatment of 
haemorrhage, endometritis, and so forth. 
A suitable sound-electrode having been ''^'''- "^le. -Switch board for shunt regulation, 
chosen, it must now be passed into the uterus. This may be done with the 
patient on her back : if, however, as is usual in this country, the gynaecologist 




314 SYSl^EM OF GYNECOLOGY 

is in the habit of passing the sound witli the patient on her left side, there 
is no reason why this position should not be retained. When the sound is 
passed the finger is still kept against the cervix in order to keep the sound 
in position, and the patient is asked to roll slowly round on to her back, and 
while she is doing this care must be taken that the sound does not slip. 
When the patient is comfortably settled on her back the connecting cord 
from the proper pole must be attached, and the handle of the sound given 
to the nurse or attendant whose duty it is to be by the side of the couch, 
and to hold the sound steadily all through the sitting. The dressing- 
gown is now to be opened, and the night-gown drawn up so as to expose 
the abdomen up to the pit of the stomach. The abdomen should be 
sponged with warm salt solution, and any abrasion, scratch, or pimple 
must be protected by a small piece of pink mackintosh or oiled silk. 
The properly prepared electrode, whether clay, flannel, or gelatine, is 
now to be carefully laid on the abdominal surface so that, in the 
case of flannel, there are no creases, and that no part of it rests on 
the bony edge of the ilium. The pad must then be pressed flrmly 
down, the connection to the other electrode made, and the blanket drawn 
up over the body. The patient is then requested to place both hands on 
the pad, and to jjress evenly and gently, so as to ensure good contact. 
The galvanometer will now indicate 2 to 5 m.a. according to the electro- 
motive force of the battery and the resistance of the rheostat. This current 
is of course not appreciable by the patient. The various binding screws 
should now be examined and tested to make certain of their being firmly 
adjusted. The slide of the highest rheostat is now slowly moved so as 
to reduce the resistance, the patient's face and the galvanometer being 
carefully watched. Then the next slide is even more slowly moved, and, 
if need be, the third, until the limit of tolerance is reached, or until the 
galvanometer shows that the necessary current strength is passing. If 
great pain is complained of before this degree is reached, inquiry should be 
made if it is general all under the pad, or concentrated at one or more 
points. If the former, the current should be reduced for a little, when it 
will generally be found that the sensation of burning disappears, and the 
current may again be gradually increased. If the pain be confined to one 
or more spots it is probably due to some tender area of skin, or to some 
irregularity in the application of the pad; in this case the current 
must be reduced by introducing the full resistance of the rheostat, and 
the pad removed and examined. A particle of salt which has escaped 
solution may be the cause of very severe local pain. If this be over- 
looked, and the current kept on, a small but very painful ulcer may be 
formed, which will take months to heal. The duration of the applica- 
tion is reckoned from the moment at which the proper current strength 
is attained: it is generally continued for 5 to 10 minutes. At the 
conclusion of this time the current is to be gradually and slowly reduced, 
beginning with the lowest slide of the rheostat, and ending with the 
highest. When the full resistance has been introduced the internal 
electrode should be withdrawn, and the pad removed from the abdomen, 



THE ELECTRICAL TREATMENT OE DISEASES OF WOMEN 315 

which is sponged with warm water and dried. The patient should then 
remain lying ou this or another couch for a quarter of an hour : after 
this she should put on her clothes. It is well to advise patients^ 
after the first few applications, to keep to a couch for the rest of the 
day ; and also on any other occasion, if any pain or red discharge follow 
the application, she should be advised to go to bed, or at least to lie 
down for the evening. It is also very important that in the course of 
an hour or two after each application the vagina should be douched 
with carbolic lotion. When puncture of a fibroid tumour or of an in- 
flammatory deposit has been practised special precautions are necessary. 
These will be discussed later. 

III. The Mode of Action of the Continuous Current. — It will now 
be convenient to consider shortly the effects on the tissues produced by 
the transmissions of continuous currents through them by means of 
metallic electrodes. This will be best understood if we study, in the 
first place, the effect of the passage of the current through a piece of 
dead tissue — say a piece of beef. A small block of fresh beef is placed 
on a dish, and into it two steel sewing needles are inserted at a distance 
of an inch from each other. One of these is connected to the positive 
and the other to the negative pole of a battery, and a current of, say, 50 
m.a. is transmitted. The following things will be observed : 1st, in a 
few seconds a frothy effervescence will appear round the negative needle, 
while the tissue will shrink and condense round the positive needle ; 2nd, 
if, at the end of a few minutes, the negative needle be gently pulled, it 
will come away without difficulty, leaving an aperture a good deal wider 
than its own thickness. This aperture opens into a sinus which is filled 
with a soft frothy scum ; 3rd, if the positive needle be similarly pulled, 
it will not come away without considerable traction, and will leave a 
small orifice with a dense, firm outline. 4th, On examination the neg- 
ative needle will be found quite bright, while the positive needle will 
be dulled and slightly corroded ; 5th, if the piece of meat be now care- 
fully cut open, so as to expose the channels formed by the needles, it will 
be found that the track of the negative needle is surrounded by a softened 
loose area of disorganised tissue, while the tract of the positive is 
surrounded by a condensed area much smaller than that round the 
negative needle, it is, moreover, paler in colour, and cuts with a some- 
what gritty sensation ; 6th, if the surfaces so exposed are tested with 
litmus paper, it will be found that on the negative side an alkaline, and 
on the positive side an acid reaction is given. 

Similar phenomena are seen as the result of the action of such 
a current on the albumin of an ^%%. If the whites of two eggs be 
placed in a glass beaker, and a current of 20-30 m.a. be passed 
through them by means of steel needles, a loose flocculent coagulum 
will form round the negative needle. After a time this disintegrates and 
floats through the rest of the fluid, leaving the needle quite clean and 
bright. Eound the positive needle a dense compact clot is formed which 
firmly adheres to it, and can be lifted out of the vessel by means of it. 



3i6 SYSTEM OF GYNyECOLOGY 

On examination by test-paper the positive clot will be found markedly- 
acid, and the negative markedly akaline. 

These changes constitute part of the phenomena of electrolysis ; and 
experiment has shown that under similar conditions identical results are 
produced in the tissues of the living body. Briefly stated, we find then 
that round the metallic surface of the negative ^o\q physical disintegration 
of tissue results with a chemical alkaline reaction, while round the positive 
pole a physical condensation of tissue results with a chemiccd acid i^eaction. 

So far as the quantitative aspects of the case are concerned we must 
keep in mind that the amount of tissue broken up at the two poles is, 
chemically speaking, identical. The basic products set free at the negative 
are chemically equivalent to the acid products set free at the positive 
electrode. 

In the present state of our knowledge it is impossible to state 
precisely the chemical nature of the products of electrolytic decom- 
position at either pole : they are highly complex. Among them, 
however, we may readily detect a certain amount of caustic soda 
and potash at the negative, and of chlorine at the positive pole. To 
w^hat extent the influence of these chemical substances may be credited 
with the production of the peculiar coagula found at the respective 
poles is a matter of some doubt, in spite of the fact that Apostoli and his 
immediate followers hold that they explain the wide difference of the 
condition of the tissues observed. On this account Apostoli terms the 
action of the positive pole " acid galvano-caustic " ; and of the negative 
" alkaline galvano-caustic." Our ignorance of the precise nature of the 
chemical and vital changes induced by electrolysis of these complex bodies 
scarcely justifies this assumption ; and further investigation is necessary 
to explain the marked difference between the influence of these poles. 

It seems safer in the meantime to accept simply that the difference in 
the action exists ; and, in cases where we seem to require a loose disin- 
tegration of tissue, to employ the negative pole ; and in others, where we 
seem to require an " astringent " or condensing effect, to resort to the 
positive pole. In other words, it is better at present in our employment 
of these currents to trust to an empirical knowledge of the effects pro- 
duced, than to attempt to guide our methods by an assumed knowledge 
of the way in which those effects are produced. 

In addition to the electrolytic effect another influence of the con- 
tinuous current is claimed by certain authors; this is termed the 
" interpolar effect." By this is meant an assumed influence of the 
current upon the tissues lying between the electrodes. It is practically 
assumed that the passage of the current produces a certain influence, 
disintegrating or otherwise, upon the molecules of the tissue which lie in its 
path between one electrode and another. To this supposed interpolar 
effect is attributed a great part of the diminution in the bulk of fibroid 
tumours and cellulitic deposits which is occasionally met with in our 
experience. Now, it is admitted that there is no physical evidence for 
the decomposition of the solution of a salt by a galvanic current save in 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 317 

the vicinity of the electrodes. The products of the decomposition 
appear round the electrodes, and so far as any direct evidence is con- 
cerned there is no proof that any change occurs in the fluids between 
these regions. Still less is there an}' evidence that electrolytic decom- 
position takes place in such a mass as that of a fibroid tumour away from 
the seat of the electrodes in contact with it. Any so-called experimental 
proof which has been advanced in favour of the existence of interpolar 
decomposition can be readily explained on other grounds ; and we may 
take it that there is no proof of any electrolytic decomposition occur- 
ring anywhere except round the metallic electrodes. 

There is abundant clinical evidence, however, that the passage of a 
current through the pelvis may have other than directly electrolytic 
effects. For example, it is a matter of common experience that, after 
two or three applications of a fairly powerful current to a uterine fibroid, 
the bulk of it will be appreciably diminished. This immediate, but in 
many cases temporary effect is oftenest produced w^hen the positive pole 
is applied to the interior of the uterus ; and it appears to be due to 
a stimulation of the muscular fibres of the uterus and tumour by the 
current, which results in a vigorous contraction and expulsion of a large 
amount of the blood contained in these structures, and a consequent 
diminution of their bulk. That this may have an important effect on the 
nutrition and growth of such a tumour seems very likely, and that its 
repeated reproduction may ultimately induce a progressive atrophy of 
such a neoplasm is no less probable. That this is the action of the 
current in many of these cases is also borne out by the fact that bulky 
and somewhat soft fibroids, after a few applications, often show a 
marked diminution in bulk ; while at the same time they become firm 
and condensed to external manipulation. Further, during this process 
of shrinkage, we may notice that large quantities of watery discharge 
are constantly escaping from the uterine cavity. 

A second effect, which one may often observe in cases under treatment, 
is the production of a sense of improved well-being which frequently is 
felt almost from the first. Every one, who has had an experience of 
any extent in the treatment of pelvic diseases by electricity, must have 
noticed how often the patient expresses herself as greatly benefited by 
the treatment long before any definite change can be detected in the local 
condition. So manifest and constant is this effect, that it would almost 
appear that these electric currents in some way induce an improved 
nutrition and a general exaltation of function in which the nervous 
system especially participates. 

IV. The therapeutic application of electricity, to those diseases of the 
female pelvic organs in which experience has shoT\Ti that beneficial 
results have followed its use, is now to be considered. 

Stenosis. — A contracted state of the os externum or of the cervical 
canal, whether congenital or acquired, can be successfully treated by 
electricity. The symptoms associated with this condition are usually 
dysmenorrhoea and sterility. In congenital conditions there is often, 



3i8 SYSTEM OF GYNECOLOGY 

though by no means always, an imperfect development of the nterus and 
ovaries ; and in these cases, of course, the main object is to relieve the 
dysmenorrhoea. These conditions can no doubt be treated in most cases 
by dilatation on one or other of the well-known methods. This, to be 
satisfactory, involves the use of an anaesthetic, for when the dilatation is 
carried to the necessary extent the pain produced is very great. Further, 
it is a matter of common experience that there is a tendency for the pain 
to recur after several months of painless menstruation ; so that, in order 
to relieve the menstrual pain, the repetition of the operation to a certain 
degree is required from time to time. 

Considerable experience with both methods seems, however, to show 
a distinct advantage in favour of the electrical treatment for these 
conditions. This treatment is practically painless; it involves no in- 
terference with ordinary duties or occupations, and its results in my 
experience have been more permanent and more completely satisfac- 
tory than those of forcible dilatation. 

The mode of treatment is as follows : — The ordinary platinum sound 
is employed as the internal electrode. With a little care this can be 
introduced into the canal without any previous dilatation ; but, if need 
be, a No. 1 or No. 2 Hegar dilator may be passed first. 

The sheath is carefully pushed up against the os, and this electrode is 
connected to the negative pole ; the abdominal pad is now applied and 
connected to the positive pole, and a current of from 50 to 80 m.a. is 
slowly turned on. This should be continued for five minutes, and then 
taken off gradually. This application should be made twice a week for 
eight or ten times. Unless an application takes place very near the 
expected time of menstruation there is no need of any special restriction 
on the patient's movements. If it happens within a day or two of the 
menstrual onset she should rest for some time afterwards. 

After two or three sittings it wdll be found that the canal is much 
more patent. It is advisable then to employ the thick sound, taking 
care always that it is not inserted too far into the cavity ; its point 
should just pass through the os internum. 

The relief given to the dysmenorrhoea is almost always immediate ; if 
only two or three applications have been made before a period sets 
in this period will be almost painless. As a rule ten applications 
of the strength indicated are enough. When the cervix is at first 
very sensitive, owing to the presence of an endocervicitis or an endo- 
metritis, the patient may not be able to bear such current strengths ; in 
these cases it is better to begin with the use of the anode internally, 
using a current strength well within toleration. After a few applications 
it will be found that the full kathodal strength can be used without 
inconvenience. 

Endometritis. — The great majority of cases of chronic endometritis 
undoubtedly yield to the various means, other than electrical, at the 
disposal of the gynaecologist. These have the advantage of occupying 
less time, a matter of considerable importance to many patients. The 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 319 

simpler measures, such as the application of caustics like carbolic acid or 
iodine, to the endometrium, if done with reasonable skill and care, are 
practically devoid of danger. But it is only in the milder cases that we 
can expect such measures to effect a cure. The more efficient and more 
drastic procedure of curettage is now found necessary in a large number 
of cases ; and it is useless to deny that this method, even in experienced 
hands, is associated with very considerable danger : the danger may be 
minimised by skill and care, but it cannot be entirely eliminated. It is. 
accordingly, as an alternative to curettage that the advantage of electrical 
treatment appears ; for, with the simplest precautions, this method is 
free from danger. Not only so, but the experience of a very considerable 
number of cases has shown that it will often cure when repeated curetting 
has failed to produce any permanent benefit. I am convinced that 
electrical treatment will cure any case curable by curetting, and will also 
cure many cases that curetting cannot cure. Against the length of time 
that it occupies we may confidently put the entire freedom from danger. 
Still, I do not advocate its use in all cases of endometritis. The time 
occupied by it, which is not less than two and often as long as three or 
four months, is a serious difficulty, and one which renders the method im- 
practicable for a considerable number of patients. In the simpler and 
more recent cases the cauterisation of the endometrium is easy and effective; 
in the more chronic and persistent cases I should certainly advise thorough 
curetting. If this is to be effective the result will show itself in a short 
time ; but if not, and if any of the symptoms return, I do not hesitate to 
advise electrical treatment as being much more likely to produce a per- 
manent cure than any number of subsequent applications of the curette. 

The symptoms of chronic endometritis are chiefly leucorrhoea, haem- 
orrhage, and local discomfort; and the predominance of one or other 
of these in any given case forms a sound guide to the proper mode of 
electrical treatment. 

Without going into a detailed consideration of the pathological 
changes in the endometrium in the various kinds of this disorder, it may 
be advisable to recall the fact that, in the glandular variety, we have a 
characteristic increase of the gland elements of the endometrium, accom- 
panied by thickening of the whole membrane, and characterised by a 
more or less profuse flow of a discharge which may be watery, creamy, or 
greenish : in the hsemorrhagic variety the membrane is greatly thickened, 
thrown into elevations, and especially characterised by a great increase of 
the vascular constituents of the structure. A third variety, characterised 
by a profuse flow of muco-pus, is distinguished by the development of 
granulations composed of an embryonic tissue. This last variety seems 
to be somewhat rare ; the great majority of the cases fall in the first 
two classes. It should be kept in mind that practically in every case of 
endometritis the uterus is enlarged ; the tissues of the wall seem swollen, 
soft, and boggy, and the organ is usually mobile, readily falling to one or 
other side of the pelvis with the inclination of the body. 

Very often the os is patulous ; this is generally the case with the os 



320 SYSTEM OF GYNECOLOGY 

externum, but in a certain number of cases the os internum is not larger 
than usual, and admits nothing thicker than the ordinary sound without 
being stretched. 

The amount and kind of the pelvic distress are very variable. In 
some cases there may be little or none; in others there may be more or 
less constant discomfort, amounting at times to severe pelvic pain. In 
most there is an unpleasant backache or feeling of weariness and fatigue 
which greatly interferes with the performance of ordinary duties. 

The details of the treatment of chronic endometritis vary with the 
nature of the conditions to be dealt with. Attention must be given to 
the special symptoms present in each case ; as we have seen these are 
generally pain, leucorrhoea, and haemorrhage. It is generally laid down as 
a guiding rule that if haemorrhage be a prominent feature the positive pole 
should be used internally, and when this is not the case that the internal 
electrode should be negative. There seems no doubt at all as to the 
propriety of the use of the positive pole in haemorrhagic cases ; the " as- 
tringent " and haemostatic influence of it is well known, and the results 
on the first menstrual period after the beginning of treatment are usually 
very striking. ISTot only does it seem effectually to destroy the haemor- 
rhagic endometrium, but it seems in a very definite way to diminish the 
bulk of the whole organ, during and for some time after each application ; 
as if it caused an emptying of the distended vessels in its walls. On the 
other hand, the wisdom of the routine use of the negative pole internally, 
in all cases of a marked leucorrhoeal type, is by no means so evident. In 
these cases the endometrium is no doubt thickened by an increase of the 
glandular or connective tissue elements of the structure, and accordingly 
the negative pole is employed on account of its supposed destructive 
action on the tissues. It is assumed, in fact, that " electrical curettage " 
is more effectually performed by the negative pole. This, however, is by 
no means clearly proved. No doubt the electrolytic results of the kathode 
are more bulky, because more loosely held together; but the actual 
amount of tissue destroyed is not necessarily greater. The affected area 
round the anode seems less than that around the kathode, because the 
affected tissue in the former case shrinks more than in the latter; but 
the tissue round the anode is as thoroughly devitalised as that round the 
kathode. As a matter of fact the influence of both poles is, chemically 
and quantitatively speaking, equivalent ; but the anodal application has 
this advantage over the kathodal, that it tends most effectively to restrain 
haemorrhage. The destruction of the diseased endometrium must often 
result in the exposure of a more or less vascular surface. Every one 
knows how some of these leucorrhoeal wombs bleed during the use of an 
ordinary curette. Accordingly, after the use of the negative electrode it 
is not uncommon to find patients losing blood for some days in greater or 
less amount ; and if a period comes on after but one or two applications 
the menorrhagia is often considerable, and this in patients in whom 
haemorrhage had not previously been a prominent symptom. Now with 
the anode used internally this is very seldom the case. As a rule in 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 321 

these cases there is a little red or reddish discharge on the evening of the 
sitting, or perhaps for an hour or two next day; but the quantity is incon- 
siderable, and never amounts to haemorrhage. When I first began to 
employ electricity for the treatment of endometritis I always employed 
the negative pole ; and to combat the hsemorrhage, used to enjoin on the 
patient the necessity of going to bed and using a hot douche, or taking 
some ergot every day while the early part of the treatment lasted : but 
in spite of this the exhaustion of the patient by persistent blood loss was 
a serious matter. Such complications are entirely avoided by the use of 
the anode. 

Moreover, the anode has another advantage in the treatment of these 
cases. A painful condition of the pelvic organs constitutes a marked 
feature in many cases of endometritis, which pain may be due to the 
inflamed state of the uterus or to altered conditions of the tubes, 
ovaries, peritoneum, or parts around ; in these cases the negative pole is 
very badly borne. The kathode, when applied to normal surfaces such 
as the healthy skin, is far more irritating to sensory nerves than the 
anode. This sensory effect is greatly exaggerated in inflamed structures, 
and accordingly it is difS.cult or impossible for many patients to tolerate 
a current of sufficient strength for any length of time if the kathode is 
used internally. On these grounds, then, I should strongly advise that, 
in all cases of endometritis, whatever the prominent symptoms may be, 
the internal pole should be anodal, at any rate at the commencement of 
treatment. In this way haemorrhage will be checked, and larger and 
therefore more efficient currents will be more easily borne. 

The mode of making the application does not materially differ from 
that of which a general description has been already given. One or two 
points, however, require notice. For the first four or five applications it 
is advisable to emjjloy the ordinary platinum sound-electrode, exposing 
as much of the metal as corresponds to the length of the uterine 
canal. In this way the whole cavity is brought under the influence of 
the current. The handle of the sound may be moved slightly now and 
then during the sitting in order to bring the platinum in contact with 
different parts of the endometrium. After four or five applications have 
been made by this instrument the thick, short platinum sound, or 
Apostoli's carbon electrode should be used, the active part being shifted 
down the cavity length by length, either at each sitting or on consecutive 
sittings. In this way the current density is greatly increased, and is 
brought to bear on each segment of the cavity in succession. 

A very careful preliminary bimanual examination should be made 
in order to determine the exact position of the os and the lie of the 
uterine body ; and in passing the electrode the greatest care should be 
exercised so as to excite as little pain as possible. If pain be caused at 
this stage it will seriously interfere with the toleration of a suitable 
current strength. AVhen the sound is fully introduced the sheath should 
be pushed well up into the cervix to protect it from the action of the 
current : the cervix is sometimes highly sensitive, and it is better, at first 



322 SYSTEM OF GYNECOLOGY 

at any rate, to concentrate the action on the endometrium proper. 
When the sound is properly placed and connected, the application of the 
abdominal pad requires some attention. It should be large so as to 
diminish the skin resistance as much as possible: if, however, it is 
known that one ovary is inflamed, or that one side of the pelvis is more 
sensitive than another, the pad must be shaped so as to avoid this region. 
To do this, and yet to obtain a sufficient surface, it may be advisable to 
shift the pad well on to the epigastrium, or as high up on the thorax as 
the mammae will permit. Some have recommended that the pad be 
placed on the back, or that an auxiliary pad be used there ; but it is 
difficult to get good contact on the back with the patient in the dorsal 
position, and a little management will enable us to get all the surface we 
want on the anterior aspect of the body. The current employed should 
be moderate at first; if 50 m.a. can be borne on the first occasion we 
should rest content. This may be kept up for eight minutes or so and 
then gradually reduced. On subsequent occasions the current must be in- 
creased ; this can be done without difficulty if care be taken, until by 
the eighth or ninth sitting as much as 150 or 170 m.a. can be borne. I 
am of opinion that in this group of cases a much stronger current is 
required than in some other groups — bleeding fibroids, for example. To 
judge from the recent writings on this subject, most operators have aban- 
doned the use of the very powerful currents — 250 m.a. and upwards — first 
recommended by Apostoli ; and in this decision I quite agree with them. 
But, while excellent results can be obtained in the treatment of bleed- 
ing fibroids by the use of currents of only 100 m.a. or even less, I be- 
lieve the best results in cases of endometritis, whether hsemorrhagic or 
leucorrhoeal, can be got only by the use of currents a good deal stronger 
than this. Hence the importance of taking all the precautions possible 
to favour the toleration of a high current, — these being, as I have said, 
the use of the anode, great care in introducing the sound, the protection of 
the cervix, and the proper application of the external electrode. A 
douche, both before and after the application, must be insisted on ; and 
if pain persist the patient should go to bed and repeat the douche (at 
105°) in the course of the evening. If there be no pain the avoidance 
of any undue exertion is all that need be exacted. The application 
should be made twice a week. The first three days of the menses should 
be avoided, but after that treatment should be resumed. As to the 
number of applications required much will depend on the circumstances 
of each case. If the patient is regular in attendance and can bear a 
medium current, fifteen to twenty-five sittings will suffice ; but more will 
be required in cases where these conditions cannot be obtained. After 
twenty-five applications have been made it is advisable to stop for a 
month, watching the symptoms; if they seem then to increase a few more 
applications should be made, but I have not met with any case in which 
twenty-five consecutive applications of average strength failed to effect 
a cure. In cases in which pain is a prominent feature, and in which the 
pain is increased by the application of the continuous current, and continues 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 323 

for some time afterwards, great advantage will be gained by the use of 
the " f aradic " or induced current. This application is made as follows : 
— the continuous current having been applied, as above directed, to the 
full tolerance of the patient for, say five or six minutes, the current is 
slowly reduced, and when zero has been reached, the electrodes are con- 
nected to the terminals of the secondary coil, which should have as many 
turns as are a.vailable. The hammer should be set to give the most rapid 
interruptions possible. The apparatus is started with the current at 
its weakest, and gradually increased until the patient begins to feel a 
sensation of numbness in the pelvis ; after which time it may be con- 
tinued for three or four minutes and then stopped. In most cases this 
completely removes any pain which may have been caused by the con- 
tinuous current. 

During a course of treatment such as this the patient should be 
advised as to the regulation of her diet and the action of the bowels ; 
and she should be encouraged in the use of reasonable exercise. As was 
previously noticed, nothing is more remarkable in these cases than the 
almost immediate effect this treatment seems to have on the general well- 
being of the patient. From the first the sense of depression, which is so 
common in this disorder, begins to lighten. Exercise becomes less and 
less a burden, appetite and circulation manifestly improve, and the bowels 
either begin to act regularly and spontaneously, or do so under much 
less artificial stimuli than they have previously required. This sense of 
improvement greatly lightens the tedium of the treatment, encourages 
the patient, and enables her to tolerate increasing and hence more effec- 
tive current strengths. 

One word by way of caution. During the whole course of treatment, 
but especially towards the end of it, sexual intercourse must be forbidden. 
As the patient improves conception may occur, say after a menstrual 
period, during and subsequent to which there may, for some reason, have 
been a somewhat longer cessation of the applications than usual. When 
these are resumed it is more than likely that abortion may be induced by 
the first application of the current. I have in my records two cases 
where profuse and persistent haemorrhage, which I can account for in 
no other way, followed an application. Indeed in one case decidual 
shreds came away for a long time afterwards. In this case, owing to 
special circumstances, the application had been in abeyance for nearly a 
month. 

Subinvolution. — A group of cases in which excellent results are 
obtained by the use of electricity are those in which, after a compara- 
tively recent pregnancy, the normal involution of the uterus has, by 
some cause or other, been checked, and it remains large, congested, and 
soft. This is, of course, most frequently seen after neglected or badly 
managed abortions occurring in the early months; and the condition is 
one which, as every gynaecologist well knows, is often the precursor of a 
whole train of morbid phenomena, organic as well as functional. Let us 
take a typical case : an abortion has occurred at, say, the third or fourth 



324 SYSTEM OF GYNAECOLOGY 

month; a few days afterwards the patient gets up, the haemorrhage 
having barely ceased ; the next period comes on in about three weeks, 
and is so profuse that the woman maybe compelled to return to bed for 
a while ; the haemorrhage ceases, she resumes her duties with the same 
result — a premature and profuse menstruation. Such a condition as 
this may continue for some months, the patient suffering seriously from 
the losses, from an intermenstrual leucorrhoeal discharge, and from 
constant and increasing pelvic distress. If the patient now comes 
under observation we find a large, soft uterus, often retroflexed and re- 
troverted, with a patulous os and some tenderness on pressure. The 
sound may pass 31- to 5 inches, and it is felt also that the walls are con- 
siderably thickened. With every care it may be impossible to avoid pro- 
ducing some haemorrhage on passing the sound. The uterus may be found 
tender, and not unfrequently the ovary on one or other side is prolapsed. 
Usually the rectum is loaded, or at any rate large doses of purgatives 
are required to produce an evacuation. We have to deal here with the 
first or congestive stage of a chronic metritis, which may be associated 
ultimately with the local and general conditions only too familiar to us 
in such cases. No doubt this condition is amenable to ordinary modes 
of treatment, but to nothing does it yield so thoroughly and so expedi- 
tiously as, in my experience, it has done to electrical treatment. 

The treatment may best be begun by a few applications of the 
induced current. For this purpose Apostoli's bipola intra-uterine 
electrode, or the ordinary sound-electrode, and a small abdominal pad 
may be used. The coil, with somewhat slow interruptions, is connected, 
and a current as strong as can be borne is applied for ten or fifteen 
minutes. This may be repeated three or four times a week for a fort- 
night or three weeks. The effect of this seems to be to increase the tone 
of the uterine muscle, and materially to diminish the congestion. At 
the end of this time it will be found that, although the cavity is not 
appreciably shortened, the walls are less flabby, certainly less thick and 
swollen ; and there is far less tendency to backward flexion. The general 
feeling of pelvic distress is also greatly relieved. The application of the 
continuous current may now be commenced. Here again the anode is 
used internally, the full length of the platinum electrode being employed, 
and the treatment carried out in the way indicated for endometritis. 
Smaller currents up to 100 m.a. will suflice. After ten or twelve appli- 
cations the uterus will be found markedly diminished in length, the 
white discharge almost gone, and the periods normal in amount and dura- 
tion. Fifteen to twenty applications will be sufiicient. If at the end of 
this time there be any tendency to displacement, a pessary should be 
fitted and worn for a few weeks. The same precaution as to the avoid- 
ance of a risk of conception must be insisted on as in the treatment of 
endometritis. 

Fibroid Tumours of the Uterus. — The great interest which in recent 
years has been aroused in the application of electricity to the treatment 
of pelvic diseases in women is undoubtedly due to the work of Apostoli 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 325 

of Paris ; it began when the account of his results in the treatment of 
fibroid tumours was published in 1886. His methods were a complete 
departure from anything which had been attempted previously, and the 
results were in themselves so striking that attention was at once arrested. 
To him, then, is due any credit which is associated with this form of treat- 
ment. No doubt a considerable number of attempts had been made to 
utilise this form of energy for the purpose of treating various forms of 
gynaecological diseases by previous workers, but the methods were crude 
and the results insignificant. A strong claim of precedence was made by 
Cutter, and by others on his behalf, in America ; but it has been shown 
again and again that the apparatus used by Cutter was quite incapable of 
giving anything like an appreciable current, and that the effects produced 
must have been due to other than electrical agency. Apostoli's position 
rests on the fact that he employed strong currents which were accurately 
measured, and which were applied on a definite principle, depending 
on the characteristic action of the different poles. He certainly was the 
first to show how the currents might be obtained, how they should be 
measured, and especially how they could be brought to bear on the tis- 
sues to be dealt with. Until he did it no current approaching 200 m.a. 
had ever been transmitted .through the human body for therapeutic 
purposes ; he showed very clearly how this could be done, and he also 
demonstrated, to a great extent, the result of such an application. 
Apostoli's communication aroused great interest all over the world, and 
very speedily a number of gynaecologists were engaged in an extensive 
series of clinical experiments to verify or disprove the results alleged by the 
originator of the treatment. Many of these experiments were of the crudest 
kind, and in some cases were attempted by men who knew little or nothing 
of the nature of the energy they were endeavouring to use, and Avith 
apparatus quite incapable of providing or applying that energy. Not 
only so, but Apostoli's statements were misread, and he was credited with 
alleging results which he never did allege. Because he said that some 
tumours diminished or disappeared, it seemed to be assumed by some of 
his critics that all tumours should disappear under this form of treatment ; 
and as they did not do so his assertions were regarded as unfounded. It 
is probable, too, that a misapprehension of the scope of the treatment 
arose from the unreasonable claims which were made for it by some of its 
upholders ; thus again a certain disappointment and sense of failure arose 
in the minds of those who were endeavouring to obtain results which should 
never have been claimed. For a time the discussion was keen, not to say 
acrimonious ; and extreme opinions were freely expressed. Time has 
allayed the turmoil of the debate, and the method, if practised by a 
smaller number, is receiving a fairer trial and is being placed on a 
sounder basis. "Apostoli's method" is now generally regarded by 
those who have given it a fair and intelligent trial as fulfilling a cer- 
tain Avell-defined, but highly important function in gynaecological thera- 
peutics ; and those who have not given it such a trial have no right to an 
opinion one way or the other. 



SYSTEM OF GYNECOLOGY 



The symptoms arising from the presence of a fibroid tumour of the 
uterus are the following : — (i) Haemorrhage; (ii) Pain; (iii) Pressure 
symptoms. These may, however, be entirely absent in some cases of 
fibroids even of considerable size. On the other hand, they are often all 
present together in one subject. 

The cause of the haemorrhage is undoubtedly the great vascularity 
induced by the growth ; and the blood seems to come not only from that 
portion of the mucous membrane which lies on the surface of the neoplasm, 
but from the whole endometrium as well. It may show itself at the 
menstrual periods only, or it may occur also during the intermenstrual time. 
The pain may arise from various causes. It may be due to the growing 
fibroid pressing upon and straining the uterine nerves, to irregular uterine 
contractions set up by the presence of the tumour, to the production or 
straining of peritoneal adhesions, and to the compression of nerves with 
which it comes into contact. 

The pressure symptoms chiefly affect the bladder and rectum, and 
often disturb their functions to a very great extent. They may also act 
on the pelvic veins, causing haemorrhoids and varicose veins of the lower 
limbs. In large tumours the effect of pressure may manifest itself on 
organs so remote from the pelvis as the stomach and heart. The most 
acute form of pressure effect is seen in the case of growing fibroids which 
have become incarcerated in the pelvis. In these cases the suffering at 
times becomes intense. 

To the relief of these symptoms, pain, haemorrhage, and pressure, the 
electric treatment of fibroids is directed. If it succeeds in relieving 
these it not only removes the danger of death (which, though com- 
paratively rare from a fibroid tumour, yet may result from sudden or 
continuous haemorrhage, or from gangrene during spontaneous enuclea- 
tion), but it also removes or greatly ameliorates all those consequences 
of the presence of the tumour which tend to interfere with the dis- 
charge of ordinary duties, and in many cases render life a daily increasing 
burden. The aim of the gynaecologist is not to remove the tumour, 
nor greatly to diminish its bulk ; it is simply to abolish those conditions 
which impair the activity of the subject of it, render her life a burden, or 
even menace her existence. 

It is to this relief of the symptoms of fibroid tumours that those who 
have systematically and carefully carried out Apostoli's method are pre- 
pared to lay claim ; and when we consider that, in the great majority of cases 
of this exceedingly common disorder, these symptoms are the only serious 
ones, it must be admitted that the claim is no insignificant one. 

I repeat it is not alleged that tumours are necessarily dispersed 
or materially diminished in bulk by electrical treatment, however long 
or energetically carried out ; that both these events happen from time 
to time is no doubt true, but the symptomatic cure which is claimed 
as the aim and result of this treatment does not depend on the disappear- 
ance or even on a considerable diminution of the tumour. To those who 
have had even a moderate experience of this method, it is known that a 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 327 

tumour whicL. was a menace to life may cease to give any inconvenience 
without undergoing any appreciable diminution in size. 

The question, then, naturally arises how these symptomatic amelio- 
rations are brought about ? How are the haemorrhage, the dysmenor- 
rhcea, and the general pelvic distress relieved by electrical treatment ? 
The answer to this question is by no means clear. That the results are 
such as I have stated is certain ; the explanation of the results is a 
matter of some doubt. One or two considerations may, however, help 
to throw light on this subject : first, as regards the arrest of haemorrhage, 
we know that the source of it is the congested endometrium ; we have 
seen that electricity will cure ordinary hsemorrhagic endometritis, and it is 
not unlikely that if a fibroid be present in the uterus the endometrium is in 
a state not unlike that found in endometritis. It is probable, then, that 
the action of the intra-uterine pole is such as to change the state of the 
endometrium and so to diminish its tendency to bleed. But it is not 
always necessary, in order to produce this control of haemorrhage, that the 
metallic electrode should come in contact with the endometrium. There 
are some cases of haemorrhagic fibroid in which, on account of the displace- 
ment of the uterus, it is impossible to introduce a sound. In these cases 
electro-puncture of the projecting mass of the fibroid may be resorted to ; 
and though, in such a case, the endometrium is never reached, the 
haemorrhage comes very soon under control. This clearly shows that, 
while electrolytic effects on the mucous membrane may be part of tlie 
explanation of electro-haemostasis, it is not the whole explanation. 
Other and more obscure effects of the electric application must play 
an important part in the process. One of these effects seems to be 
the distinct, though limited and probably temporary, shrinkage of 
the tumour, which is probably due to the stimulation of the muscular 
tissue of the uterus and tumour ; for there seems no doubt that those 
tumours which contain most muscular tissue are most susceptible to treat- 
ment. This shrinkage can be inferred from these two facts : firstly, after 
a sitting in which the positive pole has been used, bimanual examination 
will give a distinct impression that the tumour has become more firm and 
condensed than before; and, secondly, in cases of tumour threatening 
impaction, although before a sitting it may often be found quite im- 
possible to raise the mass out of the pelvis, or even to shift its position, 
and that the attempt to do so causes intense pain, yet immediately after 
the sitting it can be pushed well up into the abdomen, with very little 
inconvenience to the patient. Such a change can only be explained by 
a change in the bulk of the tumour. It seems, then, quite likely that the 
haemostatic effect may, to some extent at any rate, be a secondary result 
of muscular contraction. 

It is well recognised, of course, that the continuous current has a 
marked effect in producing powerful contractions of the uterus. This can 
be demonstrated experimentally; and it is shown clinically by the consid- 
erable number of intra-uterine fibroids which have been expelled during 
electrical treatment, in some cases after a very few applications. It is 



328 SYSTEM OF GYNECOLOGY 

further quite probable that we must look to this contraction-producing 
effect for an explanation, not only of the hsemostatic results, but also of 
the alteration of nutrition and consequent diminution in size which not 
infrequently result from electrical treatment. 

The pathology of fibroid tumours and their clinical classification have 
been dealt with in another part of this work. 

The indications for electrical treatment must now be considered, and 
on the other hand the conditions, whether in the tumour itself or its sur- 
roundings, which forbid its use. To take the latter first, we may enumerate 
the following conditions : — (a) Tumours which give rise to no symptoms 
of haemorrhage or pain, and which are either small enough to lie comfort- 
ably in the pelvis, or are large enough to occupy part of the abdominal 
cavity, are generally subserous, and in many cases are connected to the 
uterus by a more or less defined pedicle. Little benefit will accrue from 
electrical treatment in these cases, however long it may be carried out : 
they are best left alone. (6) Tumours belonging to the fibro-cystic type 
are not amenable to electrical treatment. These often grow rapidly, and 
are usually associated with a sero-sanguinolent discharge, often profuse in 
amount : it is almost universally admitted that electricity has little 
influence on them, and prolonged attempts may tend rather to increase the 
amount and frequency of the haemorrhage. Moreover, the electrical 
application seems to have no influence in controlling the growth of these 
tumours, probably owing to their scanty and disorganised muscularity, 
(c) The soft, gelatine-like fibroid (the " oedematous " fibroid of Tait) has 
many clinical characters in common with the fibro-cystic variety. It seems 
in all cases to resist electrical treatment, and is indeed apt to undergo 
reactions of an unsatisfactory and undesirable kind on persistent attempts 
at treatment, (d) The presence of any degree of purulent salpingitis 
ought to be regarded as an absolute contra-indication. In the first place, 
this complication renders the tolerance of an effective current impossible ; 
and, secondly, it has been found that even small currents (20-30 m.a.), if 
administered in such cases, are always followed by an increase in the local 
pain, sometimes by rigors and by a rise of temperature. Such sequelae 
must be regarded in any case in which they occur as an absolute contra- 
indication, (e) A chronic peritonitis in connection Avith a fibroid, which 
has set up firm adhesions of the tumour either to the parietal peri- 
toneum or to adjacent viscera, must be approached with much caution. 
It is undoubtedly a fact that some of these cases of peritoneal adhesions 
yield in a remarkable way to the use of electrical treatment, and in them 
the procedure is more than justified. In others, however, the same 
reactions as those noted under (d) appear, and in them further attempts 
must be abandoned. Accordingly, in such cases tentative measures 
with a very weak current at first may be tried, the results being carefully 
noted and subsequent procedure thereby regulated. 

Turning now to the indications for the electrical treatment of uterine 
fibroids, we may make the general statement that all fibroids — whether 
submucous, interstitial, or even subperitoneal — which give rise to hsemor- 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 329 

rhage or pain, which do not belong to the pathological varieties above 
noted, and which are not complicated with suxjpurative or inflammatory 
conditions in the uterine annexa, are fit for treatment by electricity. 

It is almost unnecessary to say that no one supposes that the symp- 
toms will be cured in every such case ; but under fair and reasonable 
conditions the pain and haemorrhage will be so completely relieved in 
the great majority of them as to remove the burden from life, and render 
existence not onl}^ tolerable, but enjoyable. 

Of the various clinical types which yield to treatment one may single 
out as specially amenable submucous tumours of moderate size, of fairly 
soft consistency, in which growth is fairly rapid, and in which the periods 
and intermenstrual haemorrhage are fairly profuse. Under this treat- 
ment the growth is distinctly arrested, the haemorrhage is reduced to that 
of a normal period, the pain, if it exists, is abolished or greatly relieved, 
and the sense of well-being is enormously exalted. And these are just 
the groups of tumours, occurring as they do most frequently between 
the ages of thirty and forty, which, by their continued and recurring 
haemorrhages, reduce activity to the lowest point, and vitality to the nar- 
rowest verge of existence. 

Method of Treatment. — We may now consider the special details of 
procedure in dealing with these cases. It cannot be too strongly kept 
in mind that success entirely depends on close attention to these details, 
to the general care of the patient, and on watchfulness in regulating the 
manner, frequency, and vigour of the applications. 

Before the sitting the patient should take a copious douche, contain- 
ing boric or carbolic acid, or some other suitable antiseptic ; the temper- 
ature of which should be between 115° and 120° F. The high tempera- 
ture seems to check any haemorrhage which may be going on, and also 
acts usefully as a stimulant. After being placed on the couch the first 
step should be the introduction of the sound. Apostoli and some others 
recommend that the abdominal pad be placed in position first, the object 
of this being to give it time thoroughly to saturate the skin and to get 
into good contact with it before the current is turned on. My objection 
to this, however, is that it necessitates the introduction of the sound 
while the patient is on her back. Most people in this country are far 
more expert in passing the sound with the patient on her side ; and as it 
is of the first importance that the sound be passed with as little effort and 
with as little disturbance of parts as possible, it is obviously better that 
it should be done in that attitude in which the greatest skill and dexterity 
are available. Moreover, the time occupied by adapting the pad is well 
spent in allowing any pain set up by the introduction of the sound to 
subside ; so that it may not in any way interfere with the tolerance of 
the maximum current. The introduction of the sound is a matter of vary- 
ing difficult}^ in these cases. Sometimes it is quite simple, sometimes it 
is a matter of extreme difficulty, involving no little dexterity and patience. 
A careful bimanual examination will often help us much in indicating 
the relations of the uterus and tumour, and the probable lie of the uter- 



330 SYSTEM OF GYNECOLOGY 

ine canal. If any difficulty is anticipated it is often wisest to use first 
the ordinary Simpson sound, with which one is most familiar, to deter- 
mine the direction of the canal and the presence of any projection which 
may cause difficulty. When this is withdrawn, and the various move- 
ments required to insert it are carefully borne in mind, the electric sound 
may often be passed with ease. The most troublesome cases are those 
in which the cervix is tilted very high up, either in front or behind, by 
the retroversion or anteversion of the tumour; and of these two the 
former is the more objectionable. The annoying thing about these cases 
is that when the tumour is moderate in size the direction of the canal 
varies from time to time, so that each sitting is complicated with the 
trouble and time spent in introducing the sound. In cases where the 
uterus is lying forward the tendency to shift is not so marked, and the di- 
rection once determined makes it easy to pass the electrode subsequently. 
The sound having been inserted, the patient turns on her back, the 
sound being held with the finger in the vagina to make sure that it does 
not shift in any way. The close contact of the abdominal pad is quickly 
assured by sponging the skin of the abdomen with hot water previous to 
its application; and by the time it is adjusted any pain set up by the 
introduction of the sound has had time to subside. The current is now 
slowly turned on, with the precautions already indicated. At the first 
sitting we should be content with a current strength of 60 m.a., or even 
less. This is usually well borne, and the patient gains confidence by dis- 
covering that any discomfort produced is moderate and easily supported. 
A duration of five minutes after this current strength has been attained 
should suffice. The positive pole should always be employed internally ; 
in bleeding fibroids this rule admits of no exception : the negative pole 
causes more pain, and is apt to be followed by free haemorrhage. After 
the current is stopped, and the apparatus removed, the patient should lie 
down on a comfortable couch for twenty or thirty minutes ; and on going 
home she should either go to bed at once, or keep to a couch for the rest 
of the evening. Before retiring for the night another hot douche should 
be taken. The application should be made twice a week, and the current 
gradually strengthened until 100 to 150 m.a. are reached. I am con- 
vinced that there is nothing to be gained from the use of higher strengths ; 
they exhaust the patient more, and have no countervailing advantage. 
Until at least eight applications have been made (that is, for about the 
first month) the patient must be cautioned against any undue exertion ; 
indeed she should rest as much as possible. Scrupulous attention must be 
paid to the action of the bowels, as troubles of various kinds may follow 
constipation even of a day's duration. The management at the periods is 
a matter of prime importance. It is commonly found, that, at the first 
period after treatment has begun — after, say, four or five applications have 
been given — the flow begins by a slight sero-sanguinolent discharge, which 
may last for three days or so before the establishment of the period 
proper. At one time I was in the habit of ignoring this flux and making 
the application as usual. This, I now think, is a mistake ; for I have 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 331 

frequently found that it was immediately followed by a very profuse 
hseniorrhage, often of a most exhausting and sometimes of an alarming 
kind. It is better to refrain from electrical treatment under these 
circumstances, to order a hot douche twice a day until the full dis- 
charge commences ; and then to advise the patient to lay up for 
three or four days. At this time — that is three or four days after the 
discharge has fairly set in — the applications may be resumed, and it 
will generally be found that the amount at once diminishes, and that 
in forty-eight hours it has entirely ceased. 

At first the long sound should be used, exposing as much of the 
platinum as will lie in the canal. When ten or twelve applications have 
been made the short, thick sound may be used, if it can be passed, and 
the cavity treated in successive segments. This is, however, of less con- 
sequence in the treatment of fibroids than of endometritis, under which 
head its use has been described. The number of applications will vary ; 
in most cases where the patient attends to instructions it will be found 
that twenty sittings will be enough. After the treatment is stopped the 
first period is usually somewhat profuse, but the succeeding ones approach 
more and more to the normal. In others ten more applications may be 
required, but this is exceptional. In any case it is advisable, after giving 
about twenty applications, to cease for a time and to w^atch one or two 
periods, and then to give a few more if this course seems to be indicated. 
Almost from the very first the improvement in general tone and vigour 
is remarkable ; the patient feels stronger, eats better, and especially 
sleeps sounder. It is, indeed, in many cases, necessary to caution her 
against the too free indulgence in exercise, to which she may be tempted 
by her increased sense of well-being. 

Next we may consider the cases in which pain is the special 
symptom. In a certain number of these the pain is chiefly dysmenor- 
rhoeal, and in them it is usually accompanied by a considerable amount 
of menorrhagia. The tumour in such cases is either situated low down 
near the cervix, the uterus being usually markedly flexed ; or the condition 
is accompanied by a considerable amount of endometritis, and is char- 
acterised by the profusion of leucorrhoea between the periods. 

In such cases the treatment should be conducted on much the same 
lines as in the group already discussed. The pain at the onset of the 
period will be very greatly relieved if, at the sitting just before the period 
is due, the short sound be so introduced that the active part lies just 
beyond the os internum, and a positive application be made of the 
maximum strength which can be borne. Many cases seem to be further 
benefited by the use of the induced current applied at the same spot at 
this sitting. Indeed I am in the habit of using both currents simul- 
taneously during the sitting previous to the period. This can be done 
most conveniently by the arrangement known as the de Watteville key, 
which is fitted to properly arranged batteries and switch boards. The 
strength of both currents should be as much as the patient can bear. 

In other cases the pain is a more constant element ; and where it is 



332 SYSTEM OF GYNECOLOGY 

not due to inflammatory conditions of the annexa, it is usually caused by 
the tendency of the tumour to become impacted in the pelvis, either as 
the result of its steady growth, or from the vascular flushing which 
precedes the period or sometimes arises from external causes, such as 
constipation. In these cases examination will show that the tumour 
nearly fills the pelvis, or else grows from the wall of a very much 
retroverted uterus. In either case it resists any attempt at displacement 
upwards ; and such attempts are always the cause of much pain. In 
many of the subjects of this condition rectal and vesical tenesmus give 
rise to added distress, the latter especially being the source of much 
misery. It is well known that many of these cases can be greatly 
relieved for long periods by a course of hot douches extending over two 
or more months. This no doubt acts by stimulating the muscular 
fibres, and so diminishing the congestion of the organ ; and this some- 
times even to such an extent that the tumour may be pushed clear of 
the pelvis, and prevented from returning to it by means of a ring or 
other pessary. In most cases, however, it will be found that a quicker, 
and in the end a much more satisfactory result may be obtained by the 
judicious use of electricity. It is more speedy, for after two or three 
applications very violent tenesmus may disappear, and it is often 
immensely relieved after a single application. But more than this, the 
influence of electricity is to check the further growth of the tumour, and 
in many cases it will actually produce a diminution of it; to lift it 
into the abdomen has no such effect, but simply gives it room to grow 
without the production of painful pressure symptoms. Take, then, a 
case in which the tumour is nearly filling the pelvis, and is causing some 
degree of vesical or rectal tenesmus. The long sound should be intro- 
duced into the uterus, special care being taken to avoid the production of 
all undue pain. If, in spite of this, great pain is complained of by the 
time the abdominal pad is applied, the electrodes should be connected to 
the induction coil, and an induced current administered, of gradually in- 
creasing strength, with the interruptions as rapid as possible, and kept 
up until a feeling of numbness is induced in the pelvis generally. 
With the large pad the current can be borne nearly as strong as the 
instrument can give, and generally the numb sensation comes on 
within ten minutes. When this is fairly established the coil may be 
disconnected and the continuous current applied, the sound being 
positive. This should be increased until 60 to 80 m.a. are reached, and 
the current should then be maintained for about ten minutes. The same 
care as to rest and the use of the hot douche must be exacted. The 
sense of relief which follows even one application of this nature is often 
very remarkable ; and after five or six sittings the patient will usually 
express herself as being quite comfortable. It is not wise, however, to 
stop at this point. Fifteen to twenty applications should be given, and 
it will usually be found long before this that the uterus is freely 
movable, and that, in the case of a retroversion, a pessary can be worn 
with perfect comfort. Of course in many cases the passing of the sound 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 333 

gives rise to no great pain, and in these the preliminary faradisation is 
not necessary. In none need the current ever exceed 150 m.a. ; and 
100 m.a. will usually be found sufficient. 

It is, however, of the greatest consequence in connection with this 
group of cases to bear in mind that some of the symptoms may be due 
to the presence of conditions in the annexa — such as pyosalpingitis — 
which absolutely contra-indicate electrical treatment. Where there is 
the slightest suspicion of the presence of such elements in the case great 
care must be employed in beginning the treatment — a small current 
being used, and any febrile reaction carefully watched for. If this 
occur, or if the pain seem in any way aggravated by the treatment, 
further procedure in this direction should be abandoned. 

The Use of Electro-puncture. — All authors seem to be agreed that 
whenever the current can be passed by the endometrium, it is better so 
to pass it. Consequently whenever the sound-electrode can be introduced 
into the uterus without resort to violent measures, this method of apply- 
ing the internal electrode should be adopted. There is, however, a certain 
group of cases in which it is impossible to pass the sound. This state of 
things is brought about by so great a displacement of the uterus, back- 
wards or forwards, by the tumour as to tilt the cervix and so put it out 
of reach; or it may arise from the downward growth of a lobule of a 
large tumour, or of one mass of a multiple tumour, the main body of 
which is in the abdomen. In these cases the roof of the vagina is gener- 
ally occupied by a hard, solid mass of spherical outline, the cervix being 
just within or altogether beyond reach. In such cases pain is usually 
the chief complaint — though, of course, haemorrhage is often present as 
well. The passage of the sound being out of the question, the only 
means of dealing with the tumour electrically is by means of electro- 
puncture. Now, while admitting the obviously greater risk involved in 
this procedure, I do not for a moment admit that the risk is in any sense 
sufficient to forbid it, if it be carried out with certain simple precautions. 
The marvellous relief which may follow the practice of puncture in 
cases in which hysterectomy is positively the only alternative, is, to my 
mind, an ample reason for its use in properly selected cases. I have 
used it many times, and I have had only one case in which its results 
gave rise to any anxiety ; in that case conditions were present which 
can be easily excluded in any other. 

The instrument employed for the puncture has been already described; 
it is simply an enlarged electrolysis needle (see Fig. 108) ; and the special 
condition of its introduction is that it be buried at least deeply enough 
to allow the sheathing to pass through the mucous membrane of the 
vaginal roof. In this way the formation of a sinus or sinuses in the roof 
is avoided. On the other hand if, as is advised by Apostoli and others, 
a bare steel or platinum needle or trocar be used, with the insulating 
sheath up to the vaginal roof, but not through it, the latter is acted upon 
by the current as well as the deeper parts, and an open channel is formed 
from the vagina to the deepest part of the puncture. 



334 SYSTEM OF GYNAECOLOGY 

For purposes of description let us take a case where the roof of the 
vagina or posterior wall is blocked by a fibroid mass causing pain and 
pressure symptoms, and where it is impossible to pass the sound. Im- 
mediately before the operation a strong corrosive or carbolic douche, 
copious enough to remove any trace of discharge of any sort from the 
vagina, must be given. The patient should then be placed on the couch 
in the dorsal position. If a bed be used it must be firm, and she must 
lie as near the edge of it as possible ; the knees must be drawn up and 
widely separated, and the feet firmly planted. As the patient must not 
be disturbed after the puncture is made, the abdominal pad should now 
be applied and its connecting cord, the positive one, attached. The 
needle, which should have been standing in a 1-20 carbolic solution, is 
now attached to the negative connecting cord and taken in the right 
hand. Its point, protected by the pulp of the forefinger, is carried along 
the vagina until the most prominent part of the tumour is felt. The tip 
of the finger is used to determine if any pulsating vessel can be felt over 
this part ; if not, the point is presented to it and steadily held with the 
right hand, while the left is employed to press on the handle until the 
point passes \ or f of an inch through the mucous membrane. The 
length can be previously marked by tying a piece of silk thread firmly 
round the insulator at the proper distance from the point. As the needle 
tapers to the point the thread, if properly tied, cannot slip up the stem, 
and an accurate guide to the depth of puncture is thus secured. 

The pain caused is very slight ; it is usually confined to that produced 
by the puncture of the vaginal roof, and is but momentary. In con- 
nection with this electro-puncture a good deal has been made of the sup- 
posed risk of injuring the bladder or other organs in introducing the 
needle. I have never seen a case where there was the slightest risk of 
such an injury. In cases suitable for puncture the pelvic roof is so com- 
pletely occupied by the tumour that no other organ can encroach upon it, 
and it is quite safe to select the most prominent part of the tumour for 
the puncture. This will usually be found well behind the middle point of 
the pelvis, where we are a good deal nearer the rectum than the bladder. 
Everything now being in position, the needle is handed to the nurse, the 
forefinger being kept in position against the roof of the vagina to make 
sure that there is no displacement as she takes charge of it. The current 
is now carefully turned on, the same precautions being observed as were 
previously described. A strength of 100 m.a. is usually borne with ease, 
and this may be continued for from five to eight minutes. As a matter 
of fact these negative electro-punctures are rather more easily borne than 
intra-uterine applications ; and, after two or three sittings, one may safely 
use currents of 150 to 200 m.a. When the current is taken off the 
needle is withdrawn, the pad removed, and absolute quiet enjoined for 
half an hour. The patient may then dress and go home, but should go to 
bed at once. A douche must be given at night, and repeated regularly 
once a day at least. There is often a little red discharge for a day or 
two after the operation, but I have never seen any serious hsemorrhage 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 335 

follow it. It is wise to allow a week between each, sitting. The same 
precautions and procedure must be rigorously observed at the subsequent 
sittings, and it is well to avoid puncturing again in the same spot until 
several weeks have intervened. For ten days or more the site of the 
puncture can be recognised by the presence of a little dimple or pucker ; 
after that time it should leave no trace. 

Apostoli and most other authors enjoin the use of the negative pole 
for electro-puncture. This has two advantages : 1st, it permits the use 
of a steel needle for an electrode ; and, 2nd, the needle is easily withdrawn 
at the end of the operation on account of the looseness of the disintegrated 
tissue. It is also supposed to have the advantage of breaking up more 
tissue than the positive. This difference is, however, rather apparent 
than real, as we have already seen. It has the disadvantage that it might 
favour haemorrhage through the puncture, if by any chance there were a 
tendency to this accident ; and it has the distinct and much more serious 
disadvantage of tending to cause a congestion of the tissues in the region 
of the puncture. In this case we should hardl}^ expect the same im- 
mediate shrinkage which we certainly get in intra-uterine positive applica- 
tions, and we should miss to some extent the immediate and gratifying 
relief of pressure symptoms which usually follows a positive application. 
There is then, it seems to me, no objection whatever to the employment 
of the positive electro-puncture if the negative fail to give the desired 
relief. A platinum needle must be used, and if, as sometimes happens 
even with platinum, the needle does not come away of itself after stopping 
the current, a negative current of not more than 2 or 3 m.a. for a few 
seconds will free it. We thus get the soothing and congestion-reducing 
effects of the anode, with probably no diminution of the electrolytic in- 
fluence of the kathode. 

In concluding our consideration of the treatment of fibroid tumours 
of the uterus by " Apostoli's method" it will be well to summarise the 
claims made for it: 1. In submucous and interstitial fibroids it controls 
haemorrhage, abolishes metrorrhagia, and restores the period to normal 
limits : 2. It relieves pain, both menstrual and intermenstrual : 3. It 
produces an immediate diminution in the congestion, and hence in the 
bulk, of an impacted tumour ; and, though this may be evanescent, it 
gives great relief to pressure symptoms, and may enable such a tumour 
to be freed: 4. The growth of submucous and interstitial tumours is 
almost always completely arrested : 5. In a certain number of cases the 
tumour is distinctly reduced in size : 6. In a very small number the 
tumour may wholly or nearly disappear: 7. The effect of the treatment 
is a symptomatic, not a radical cure. 

Pelvic Exudations. — The frequency with which perimetric and para- 
metric exudations occur in the female pelvis, the disorganisation of func- 
tion they cause, and the pain and distress they bring with them, are well 
known to every gynaecologist. Nor is he less well aware of the persistence 
of these deposits, and of their power of resistance to almost every form 
of treatment to which they can be subjected. 



336 SYSTEM OF GYNECOLOGY 

These exudations may take the form of a bulging mass, in one or 
other or both sides of the uterus, of a dense, firm, and unyielding quality, 
fixing the uterus and displacing it to one or other side. This form is 
usually the result of a cellulitis beginning in the cellular tissue of the 
roof of the vagina on one side, sometimes being confined to that side, but 
often finding its way to the other. Again, one may find a dense mass 
behind the uterus, occupying the pouch of Douglas ; not bulging to any 
extent into the vagina, but binding the uterus to the posterior or lateral 
aspects of the pelvis. This is most frequently the result of a peritonitis, 
and, like the cellulitis, is generally septic in its origin. In other cases 
the whole pelvic viscera maybe matted together, the pelvis being roofed 
in, as it were, by the inflammatory exudation, partly perimetric, partly 
cellulitic. The tendency of these deposits in the early stage of their 
history to suppuration is well known ; but in many cases this does not 
occur, and the mass remains unchanged for months and years, a constant 
cause of pain and distress, of dysmenorrhoea and menorrhagia, reducing 
the subject to a state of profound debility and misery. The treatment 
of these deposits is often one of the most tedious and disheartening ex- 
periences of gynaecological practice. Some of them, no doubt, become ab- 
sorbed, either spontaneously or as the result of treatment ; but in other 
cases, the treatment by blisters, iodine, ichthyol, hot water, glycerine, 
and other remedies, proves futile, and the condition remains unaltered 
for an indefinite time. 

It is in the treatment of some of these obstinate and previously hope- 
less conditions that electricity has achieved some of its most brilliant 
triumphs. However great may be the difference of opinion as to its 
efficiency in the treatment of fibroid tumours, few physicians who have 
given its virtues a fair trial in the present class of cases, or have watched 
the course of a case under treatment, are not compelled to admit that its 
beneficial results are most striking. I have seen an enormous exudative 
mass, which was proved by an exploratory incision to have roofed in the 
pelvis and filled every fold of the peritoneum with a solid deposit, dis- 
appear after twenty -five applications of electricity ; indeed it required a 
careful examination by an expert to say that there was anything abnormal 
in the pelvis. And the patient, who had spent years in bed as a helpless 
invalid, at the end of a few months' treatment was able to take a five 
miles' walk without discomfort or undue fatigue. 

The value of this treatment in these cases cannot well be overrated. 
Apostoli, Goelet of New York, and others, are strongly in favour of 
beginning the treatment of cases of this kind during the acute stage, 
when fever, pain, and the actual process of exudation are going on. 
They advise the use of intra-vaginal faradisation with the fine wire coil, 
asserting that this relieves the pain, calms the patient, and diminishes 
the amount of exudation. They recommend that a bulbous metallic 
electrode be placed in the affected fornix, and gentle faradisation carried 
on until the pain is relieved, a process which occupies fifteen or twenty 
minutes, and that this process should be repeated once or twice daily. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 337 

In the subacute stage the continuous current may be substituted, a cotton 
or clay covered vaginal electrode being used, and a pad on the abdomen. 
The current strength may vary from 20 to 30 m.a., the anode being 
used internally. This again is said to diminish the pain and to reduce 
the exudation. These applications may be made every second day. 
The only contra-indication to this line of treatment, according to these 
authors, is an intolerance of the application on account of increase of 
pain and rise of temperature. These events are probably indications of 
a change in the direction of suppuration which is generally regarded as 
being an absolute contra-indication. 

I have had no experience of this treatment at these stages of the 
disorder, and cannot therefore speak of it with any authority. But in 
the chronic condition, when all active change has ceased, and when the 
mass has assumed its firm, dense, immovable character, I can speak of 
the value of electrical treatment with every confidence. When the mass 
has the general character of a cellulitis — when, that is to say, it is lateral 
to the uterus and bulges into the lateral fornix — I believe the best results 
are to be obtained from electro-puncture; and, following the general 
practice, I have always employed the kathode in these cases, though here 
again I should suggest that this rule need not be binding. The plan of 
procedure is precisely the same as in the puncture of a fibroid ; only, I 
should advise that the first few punctures be done at the patient's house 
so as to give her the benefit of complete rest after the sitting. The 
current strength should not exceed 50 m.a. on the first three or four 
occasions, but it may then be gradually increased until 100 or 150 m.a. 
are attained, provided no unfavourable reaction follow. After a variable 
number of applications, say three to six, it will be found that the bulging is 
steadil}^ diminishing, and that it becomes more and more difficult to 
define a suitable spot for insertion of the needle. When this occurs the 
subsequent resolution is generally rapid. It seems undoubtedly to be 
favoured, however, by a systematic pursuit of the treatment by intra- 
uterine application, and this should now be substituted for the punctures. 
In a comparatively short space of time, varying from two to four months, 
according to the extent of the deposit, the treatment may be completed. 
This will be determined by the almost complete disappearance of the 
mass, by the mobility of the uterus and ovaries, and by the nearly entire 
cessation of pain and pelvic distress. 

In retro-uterine perimetric exudations, where a defined mass can be 
felt, a similar procedure may be resorted to. On account of the greater 
difficulty of securing this definition, the puncture should be made with 
great caution, and should never exceed half an inch in depth. The 
change in the mass of adhesions which follows necessitates an earlier 
resort to intra-uterine applications than in the case of parametric 
deposits. On account of the pain which the negative pole always sets 
up, these, at any rate, at first should be anodal. In my experience, 
perimetric exudations are dispersed more slowly than parametric ones ; 
one explanation probably being that the former can tolerate smaller 



338 SYSTEM OF GYNECOLOGY 

current strengths than the latter. But the ultimate result in the 
majority of both cases is the same ; namely, an almost complete disper- 
sion of the deposit, restored mobility of the pelvic organs, and an 
enormous relief from pain. 

E,. Milne Mukray. 

REFERENCES 

A complete bibliography of gynaecological electrotherapeutics will be found in 
Le Courant continu en Gynecologic, by Dr. Albert Weil, Paris, 1895, embracing 
almost every paper bearing on the subject from 1857 to 1895. 

The following are some of the more important contributions with reference to 
Apostoli's method : — 

1. Apostoli. "Nouveau traitement des fibromes de I'uterus; lecture faite de 29 
juillet a I'Academie des sciences," Comptcs rendus, 1884. — 2. Ibid. " Sur nouvean 
traitement electrique des perimetrites," Comptcs rendus Congres de Copenhague, ii. 
141. — 3. Ibid. "Documents pour servir h Fhistoire de I'electrotherapie des fibromes 
uterins," Revue intern, d' electrique, 1891. — 4. Carlbt. Traitement electrique des 
fibromes uterins. These de Paris, 1884. — 5. Ibid. " Traitement electrique des tumeurs 
fibreuses de I'uterus d'apres la methode du Dr. Apostoli," Ann. Soc. de med. de Gand., 
1885.— 6. Engelmann, F. "Die Elektricitat in der Gynakologie," Arch. f. Gyndk. 
xxxvi. p. 193. — 7. GoELET. The Electrotherapeutics of Gynsecology. Detroit, 1892. 
— 8. International System of Electrotherapeutics. Philadelphia, 1894. See various 
articles by Grand and Famarque, Goelet, Kellogg, etc. — 9. Keith, Thomas. "Dr. 
Apostoli's Treatment of Uterine Fibroids," Brit. Med. Journ. 14th July 1888. — 10. 
Keith, Thomas and Skene. The Treatment of Uterine Tuynours by Electricity. 
Edinburgh, 1889. — 11. Kellogg. "Summary of my Personal Experience with 
Electrolysis in the Treatment of Fibroid Tumours," Journ. Amer. Med. Assoc, vol. 
xviii. 1892. — 12. Martin, Franklin H. "Electrolysis in Gynaecology," Journal 
Amer. Med. Ass. Chicago, 1886, p. 61. — 13. Ibid. Electricity in Diseases of Women 
iind Obstetrics. Chicago, 1893. — 14. Massey, Betton. Electricity in Diseases of 
Women. Philadelphia, 1889. — 15. Munde. "My Recent Experience with Electricity 
in Gynaecology," Am. Journ. Obstet. June 1890. — 16. Murray, Milne. "The Treat- 
ment of Pelvic Disease by Electricity," Trans. Edin. Obstet. Soc. 1890. — 17. Nagel. 
" Ueber die elektrische Behandlung der Frauenkrankheiten, besonders der Myome." 
Zeit. f. Geburts.u. Gyne. Bd. xxii. Heft 3, 1893. — 18. Playfair. Electricity in the 
Treatment of Uterine Disease, 11th June 1887 and 14th January 1888.-19. Regnier. 
Traitement des maladies des Femmes par Velectricite. Paris, 1896. — 20. Webb. "On 
the Treatment of Fibroid Tumours of the Uterus by Electricity," Brit. Med. Jour. 
May to July 1887. — 21. Weil. Le Courant continu en Gynecologic. Paris, 1895. 

E. M. M. 



DISORDERS OF MENSTRUATION 339 



DISORDERS OF MENSTRUATION 

The line of demarcation between menstruation which conforms to the 
normal order, and menstruation which presents features sufficiently 
abnormal to permit of its being considered disordered, is very difficult 
to draw. Menstruation which would be normal in one woman, might in 
another be regarded as painful, or profuse, or scanty ; even in the same 
subject, many deviations from the rule are perfectly consistent with 
health, and are not necessarily due to any local disease. In this 
article the various deviations from normal menstruation will be dis- 
cussed; they are but symptoms, and when due to gross pathological 
lesions the description of these must be sought elsewhere. The prom- 
inent disorders are amenorrhoea, menorrhagia, and dysmenorrhoea, but 
before reaching a consideration of these, it will be well to discuss the 
(questions of premature and protracted menstruation. 

Premature Menstruation. — Menstruation usually begins in the fif- 
teenth year, and ends between forty-five and fifty ; thus menstrual life 
normally lasts from thirty to thirty-five years. But menstruation 
occasionally sets in at a much earlier age. One case was recorded by 
Campbell, in which a girl had menstruated regularly every three weeks 
since birth. In many of these cases of precocious menstruation the 
general and sexual development is premature ; the pubis becomes 
covered with hair, the mammae enlarge, and both the external and 
internal generative organs undergo rapid development. 

I have tabulated the cases found recorded under the following heads ; 
and, where the case seemed one of more outstanding peculiarity, I have 
shortly epitomised its history : — 

1. Precocious menstruation with an early appearance of the external 
manifestations of puberty. 

2. Precocious sexual development without menstruation. 

3. Menstruation previous to development of the sexual organs. 

4. Early conception and pregnancy. 

5. Premature sexual development associated with tumours of the 
generative organs. 

1. One of the most striking cases illustrative of the first group is 
the oft quoted one of De Beau, to the record of which he considered it 
advisable to append the signatures of four physicians, a mayor, and a 
British consul. 

The history is as follows: — "Matilda H. was born on the 31st 
December 1829. She came into the world with her mammae perfectly 
formed, and the mons veneris covered with hairs, as much as a girl 
between thirteen and fourteen years old. When precisely three years 
old the catamenia made their appearance, and have continued to appear 
regularly every month until the present time (1832), and as copious as 
any woman might have them, each period taking four days. . . . Her 



340 SYSTEM OF GYNECOLOGY 

mammae are now of the size of a full-grown orange; and the dimensions 
of the pelvis are, in my opinion, such as to enable her to bear children 
when eight years old, and very likely sooner." 

In Campbell's case (2) the catamenia set in a few days after birth, 
and occurred regularly at periods of three weeks and two or three days. 
This order continued until the patient died at the age of four years. 
Her appearance was that of a girl of ten or eleven, the mammae and 
external genitals having the appearances proper to puberty. The 
development of the pelvis and of all the deep-seated genitals was found 
at the autopsy to be very considerable. 

R. B. Smart gives a table of eight recorded cases, and describes in 
full detail a case which came under his own observation, with two 
accompanying photographs of the patient. The catamenia in this girl 
appeared at three years and six months, and the hair on the pubis 
shortly antecedent to that. 

Bouchart narrates the history of a girl, N. 0., and the appearance 
she presented at the age of four years. She had been born with the 
breasts notably enlarged, she began to menstruate at the age of twenty- 
two months, and at the time of examination she presented the appear- 
ance of puberty as regards her breasts and genitals. Menstruation in 
her case was very regular in its recurrence, it lasted four to six days, 
and was in quantity equal to that of an adult. 

Harris classifies precocious menstruation in two varieties : 1st, 
that occurring during infancy; 2nd, that occurring between the ages 
of seven and thirteen years. He records the case of a girl who came 
under his own observation, in whom menstruation appeared at the age 
of nine and a half years, and in whom the other evidences of puberty 
manifested themselves. 

C. E. Harle records the result of a post-mortem examination on a 
child who had begun to menstruate at the age of five months ; the 
menstruation returned regularly till the fourteenth month, when the 
child died of diarrhoea. The pudendum was large and clothed with hair ; 
the uterus was large, the os patent and the lips congested, the vessels 
of the broad ligament were injected, and both ovaries were cystic. 

The other cases I have noted under this category are the following : — 



[Table. 



DISORDERS OF MENSTRUATION 



341 



Author. 


Menstruation 


External Appearances 


began at Age of 


of Puberty. 


Astley Cooper in Med. and Chir. Trans. 


3 years. 


In breasts, axillae and on 


1813. 




pubes. 


Thomas Erabling in Lancet, 1848. 


2 years. 


Mammae and pubes. 


Aveling in Lancet, 1866, gives a refer- 






ence list of sixteen cases by different 






observers. 






Prochownik in Arch.fiir Gynaek. 1881. 


1 year. 


In breasts, axillae and on 
pubes. Internal or- 
gans not enlarged. 


Berry in Medical Press for 1882. 


5 years and 4 
months. 


Breasts and genitals. 


A. van Denver in. Am. Journal of Obstet. 


4 months. 


Mammae greatly enlarged. 


1883. 






Four of the following cases are cited by 






Pozzi in his Gynecologie : — 






Cabade in Gaz. mid. di Paris, 1883, 


8 months. 


Rapid development. 


"Wallent in Dissert. Inaug. Breslau, 


1 year 3 




1886. 


months. 




Casati in II. Raccoglitore, 1886. 


6 years. 


Rectal examination, 
" litems puhere." 


Diamant in Intern, klin. Rundschau, 


6 years. 


Extl. genitals. 


1888. 






Jagoe in New York Med. Journ. 1889. 


2 years. 


Extl. genitals. 



2. The indication of a sexual precocity, manifested by the outward 
signs on the breasts and pudenda, but unaccompanied by a menstrual 
discharge, is unusual. Eew instances of this character have been noted, 
but that described by William Cook is distinctive enough. 

3. Menstruation occurring without any change in the genitals is not 
so unusual as the preceding, but it is rare for a child to have the 
catamenia established for a period of years without other associated 
phenomena presenting themselves. 

Pozzi cited Bernard's case of a girl who menstruated regularly 
from birth up to the age of twelve years without any development of 
her genital organs. 

In the same class may be included the cases noted by the following 
authors : — 

Allbutt reports a case where the menstrual discharge occurred 
periodically until the youthful patient died of exhaustion. 

Clarence Harding reports that in a family of two daughters both 
suffered for a time from a periodic discharge, hyemorrhagic in character, 
in the elder of whom the discharge vanished until puberty was estab- 
lished, when it recurred. 

4. Many remarkable instances of early pregnancy have been put 
on record by trustworthy authorities; the majority of those in this 
country have occurred after the age of twelve. There is, however, in 
continental literature no great scarcity of reports of pregnancies at a 
much earlier age. 



342 



SYSTEM OF GYNAECOLOGY 



The following table of cases which I have collected from various 
sources has been arranged in order of age. The majority of the records 
bear evidence of being trustworthy : — 



Author. 


Reference. 


Develop- 
ment. 


Menstrua- 
tion. 


Impregna- 
tion. 


Dehvery. 


state of 
Child. 


Muller. 


Cyclop. of 
Ohst. and 
Gynec. 


Excessively 
at birth. 


2nd year. 


S years. 


Instrumental, 
8-y months. 


Dead. 


Schmidt . 


Esftais Histo- 


Sexual organs 


2nd year. 




8 years 10 


Full term, 




rigues, 1779. 


developed. 






months. 


dead. 


Bodd . 






1 year irreg- 
ular, 7 
years reg- 
ular. 




8 years 10^ 
months. 




Molitor 




Hail- on pubis 


4th year. 


8 years and 


Premature, 


Foetus — a 3 






ill iiu-tti. 




3 months. 


5th month. 


months'. 


Dodd . 


Lancet, 1881. 


Pubes and 
axilla cov- 
ered with 
hair. 


12 months. 


8 years and 
10 months. 




Weighed 7 
lbs. 


Rowlett 


Tra7is. Med. 
Jour. 


A few weeks 
after birth. 


12 months. 


9 years and 
3 months. 


10 years. 


7t lbs. 


BaylisB 


Brit. Med. 




9 years and 




10 years and 


Alive, weigh- 




and Surg. 




10 months. 




8 months. 


ed 8 lbs. 




Jour. 1846. 












Robertson . 


Midioifery. 






12th year. 


12 years and 
a few 
months. 




Smith . 


Lond. Med. 
Gazette, 

1848. 


No history. 


10 years. 


11 years. 


12^ years. 


Fully devel- 
oped. 


May . . 


Lancet, 1880. 




Once before 
conception. 




13 years. 


Well devel- 
oped. 


Heywood 


Brit. Med. 




12 years and 


12 years and 


13 years and 




Smith 


Jour. 1881. 




6 months. 


8 months. 


4 months. 




Wilson 


Ed in. Med. 
Jour. 1861. 


No precocity. 




12 years and 
9 months. 


13 years and 
6 months. 


Full grown. 


Chapman . 


AsfiOG. Med. 
Jour. 1856. 






13 years and 
1 month. 


13 years and 
10 months. 


Full grown. 



5. It has been asserted that among the causes tending to produce 
changes in the sexual apparatus peculiar to puberty we should include 
neoplasms affecting or related to the internal generative organs. This 
would appear, however, to be far from the usual rule, and to be rather 
the exception. In order to ascertain the frequency of this occurrence, I 
have examined the records of twenty-six laparotomies performed on 
children under puberty ; and in one case only did there seem to have 
been signs so marked as to arrest the attention of the operator so 
strongly as to induce him to give a description of the child's appearance. 
On this one occasion the narrator and operator was Mr. R. Clement 
Lucas. 

The child was aged seven, and had had a haemorrhagic discharge 
from the vagina, which occurred whilst she remained in hospital. The 
mammae were lirm, and about the size of oranges ; the mons veneris 
was of unusual elevation, and covered with hair about one inch in length. 
There was a tumour of the right ovary, which was removed, and the 
child made a good recovery. The vaginal discharge disappeared, and 
the mammary prominence subsided before she left the hospital. 



DISORDERS OF MENSTRUATION 343 

Premature menstruation is in a large measure hereditary ; but a more 
important factor seems to be immoral associations. iSTeglected children 
by coming in contact with vicious girls older than themselves frequently 
have their attention prematurely directed to the sexual organs. Bad 
habits, too, the result of irritation produced by ascarides in the rectum, 
want of cleanliness, or caseous secretions about the clitoris, may lead to a 
precocious development. Over-excitability of the brain has also been 
considered by some authors as a factor in the production of a too early 
puberty. 

The management of such cases consists in removing the cause as far 
as possible. Masturbation should be prevented by careful supervision 
of the child and by the relief of local irritations. General rest and 
tonic treatment with removal from nervous excitement should be 
advised. 

Protracted Menstruation. — A history of this condition is to be re- 
ceived with caution. Women past the menopause are apt to consider any 
intermittent or irregular discharge as a continuation of the menses. Such 
a hsemorrhagic discharge is, however, in most cases due to the existence 
of some distinct pathological lesion ; such as senile uterine catarrh, poly- 
pus, fibroma, and especially cancer : it is sometimes associated with a 
gouty diathesis. Nevertheless, some authentic cases have been recorded 
in which normal menstruation continued even till the fifty-seventh year. 
But it may be taken as an ascertained fact that, so far as normal 
menstruation with accompanying ovulation is concerned, authentic 
cases of pregnancy are not recorded after the age of fifty-two, or of 
fifty-four at the outside. It is safe, therefore, to presume that these 
ages indicate the extreme limit of normal menstruation accompanied 
by fertility. 

Amexorrhcea, or absence of the menstrual discharge, is primary when 
the patient has never menstruated at all ; secondary when menstruation 
has previously taken place. It exists as the normal condition during 
pregnancy and lactation. 

Primary Amenorrhoea. — (a) Primary permanent amenorrhoea. — The 
most marked cases are those in which the ovaries, or uterus, or both, 
continue in a rudimentary condition, or are altogether absent, while 
the external genitals are normally formed. The girl's sexual develop- 
ment ceases, and her characteristics, physically and mentally, tend to 
the masculine, or at least to a mixed type. The cause is absolutely 
unknown. Heredity, or interruption of normal embryonic development, 
or interference with it, cannot be accepted as satisfactory explanations. 
Nothing can be done to relieve the condition. 

Cases of this kind may be grouped in two classes : one is charac- 
terised by complete absence of sexual development. The mammae are 
undeveloped, the pubes bare (which is specially characteristic), and the 
uterus and ovaries are found on vaginal examination to be rudimentary, 
if not altogrether absent. The second class consists of cases of women 



344 SYSTEM OF GYNECOLOGY 

usually of "masculine" habits — acrobats, for example; in them the 
mammae are well developed, the upper lip is hirsute, there is a copious 
development of hair over the pubes, and on vaginal examination the 
uterus and ovaries are found, if not normal in size, very nearly approxi- 
mating to the normal. Such cases seem to be accounted for by the fact 
that the muscular development of the woman has been pressed from 
early girlhood to such an extent as to interfere with the usual function 
of the reproductive organs. 

(6) Primary temporary ame7iorrhoea may be due to chlorosis occurring 
in girls under the age of puberty. In this condition the vascular system 
is at fault ; not only are the walls of the vessels themselves imperfect, 
but the blood contains rather fewer red corpuscles than is normal, and 
they are especially deficient in hsemoglobin. In such cases, however, 
there is a tendency to plumpness from undue development of adipose 
and cellular tissue. The general appearances and symptoms of such 
patients are well known. Menstruation occurs later than normal, and 
when it does set in the flow is scanty and of short duration ; the inter- 
menstrual periods also are longer. 

The treatment is the ordinary treatment of chlorosis : it consists in 
the administration of arsenic and iron ; rest at first and exercise later ; 
careful non-fattening diet and saline purgatives. In many cases the 
digestion is also at fault, and has to be rectified by the usual 
stomachic remedies. If circumstances permit, much advantage may 
be derived from a course of the waters at such places as Tarasp and 
Schwalbach. 

(c) Delayed puberty. — Here the general and sexual development are 
complete, and yet the girl fails to menstruate. These cases are some- 
times accounted for by the fact that the "nutritive forces have been 
directed towards the general organisation." Some such girls have often 
too much physical labour. Thus among the poor, who do a great deal 
of manual outdoor work at an early age, menstruation is often delayed. 
On the other hand, brain workers often exhibit the same symptom ; by 
overwork of the higher functions the nutritive and reproductive systems 
are thrown out of balance. 

The management of such cases is easy and attended as a rule by 
satisfactory results. Change of occupation, rest for the body if the 
physical strength has been overtaxed, and rest for the mind when its 
faculties have been strained, will generally eifect a cure. 

Secondary Amenorrhoea. — This may be the result of various patho- 
logical conditions. Thus it may be due to such constitutional derange- 
ment as results from ansemia, chlorosis, diabetes, Bright's disease, malaria, 
cancerous cachexia, tuberculosis, acute illnesses, and fever. In the same 
way acute or chronic surgical affections may be potent in producing 
amenorrhoea. Some authors lay much stress upon the amenorrhoea 
which is the occasional result of syphilis. This symptom, however, is 
no doubt due simply to the anaemic condition which is associated with 
the disease. 



DISORDERS OF MENSTRUATION 345 

The suppression of the menses that occurs in young obese women is 
to be accounted for in the same way. 

The influence of the nervous system is distinctly a factor in the pro- 
duction of amenorrhoea. Thus a sudden fright has not infrequently been 
known to cause a temporary suppression of the menstrual flow — as when 
iin unmarried woman supposes herself to be pregnant; on the other hand, 
it must not be forgotten that in a few cases a stimulating rather than an 
inhibitory action has been known to follow a sudden emotion, and men- 
struation has set in. Again, amenorrhoea due to the influence of the 
nervous system is shown in the insane, and in prisoners, a change which 
is due no doubt to the mental depression consequent upon seclusion. 
Chills are very commonly responsible for the cessation of the menstrual 
flow, and in such cases the influence may be conducted through the 
vasomotor tract. 

The amenorrhoea of pseudo-pregnancy occurring in the newly married, 
in those Avho have been leading irregular lives, and in those who are 
reaching the menopause, is well known, and is to be accounted for by 
an influence acting through the nervous system. Pozzi defines it by 
attributing it to " auto-suggestion." 

Amenorrhoea often occurs in young girls who are sent to Germany 
or France to school; when the change of climate and diet appears to 
lead to this symptom. Similarly, a long sea-voyage may produce such 
a condition. 

The local diseases which cause suppression are many. Atrophy of 
the uterus commonly leads to it, and this may be the result of super- 
involution from repeated pregnancies, prolonged lactation, or tuberculosis. 
80, too, many cases are recorded in which an early menopause has occurred 
without apparent reason : menstruation gradually or suddenly ceases, 
and on examination the internal generative organs are found in the 
atrophic state of a normal climacteric. 

Tumour of the ovary may not interfere with menstruation in any 
way ; but occasionally, when both ovaries are completely destroyed by 
cystic or other degeneration, menstruation ceases. If but one ovary be 
affected menstruation may go on fairly regularly, as it may when the 
ovaries are the seat of inflammatory changes. In the early stage of 
inflammation the tendency is rather to menorrhagia ; but in the later 
sclerotic stage amenorrhoea does occasionally though rarely occur. 

Amenorrhoea due to atresia of the cervix or vagina or hymen is a 
condition which demands special attention. This is not the place in which 
to discuss the deformities producing hsematometra and hsematokolpos, in 
each of which menstruation is prevented by the occlusion of the genital 
canal. In most cases the condition can be distinguished perfectly well 
from amenorrhoea due to non-development or to constitutional causes ; 
whereas in the latter there are none of the local or constitutional dis- 
turbances which accompany menstruation, in the former pain and dis- 
comfort are manifested with regularity everymonth, and a well-marked 
bulging may be discovered at the vulva ; or a tumour may present itself 



346 SYSTEM OF GYNAECOLOGY 

suprapiibically. This tumour may sometimes be so high as to be mis- 
taken for one of the abdominal organs ; this was notably the case in a 
young girl under my own care, where a round tumour presented itself 
well up in the ilio-lumbar region which was mistaken for an enlarged 
kidney. The misleading point was that the girl had constant pain in 
this region. As, though eighteen years old, she had never menstruated, 
an examination was made of her vulva, and the tense, bulging, imper- 
forate hymen was discovered. This was treated in the usual way with 
a thermo-cautery ; slow removal of the contained fluid was accomplished 
with complete antiseptic precautions, the whole ilio-lumbar swelling 
disappeared, and regular menstruation was established. 

Removal of the Ovaries. — Whether removal of both ovaries causes 
cessation of menstruation or not, there are two classes of cases to be 
considered: firstly, those in which an excised ovary was the seat of 
tumours, cystic, papillary, or solid; and, secondly, those in which the 
ovaries on removal were either healthy, or were removed on account of 
some inflammatory or slightly cystic condition, or on account of dys- 
menorrhoea. As regards the first class, it is often difiicult to state for 
certain that the whole of the ovary has been removed ; a small portion 
may be left in the pedicle, and this may be quite suflicient to account 
for the continuance of menstruation. As regards the second class, it 
has been affirmed by Lusk that in the great majority of cases (86 per 
cent) menstruation ceases, if not at once, at least within a year of the 
removal of the ovaries. In these cases some authors have supposed the 
existence of a supplementary ovary ; but surely the " law of persistence 
of habit " is sufficient to account for the phenomenon. It is an auto- 
matic ebb and flow produced through the influence of the nervous 
system. 

Another factor in the production of this continuation of menstrua- 
tion after oophorectomy is the condition of the uterine mucosa. This is 
frequently in a congested, if not in an inflammatory condition, and for 
this reason some operators advise that, in all cases, curettage of the uterus 
should be performed after the removal of the appendages. Czempin 
considers it possible that the cicatrisation following the operation may 
compress the veins, and so keep up a passive congestion and a continuance 
of the monthly flow. Oophorectomy not only leads to local disturbances, — 
chiefly to amenorrhoea, — but it is apt to lead to general physical changes. 
There is an increase of plumpness of the person, although the mammae 
generally atrophy ; and there is frequently a change of disposition, which 
often becomes more placid. 

If the Fallopian tubes alone are removed, the ovaries being healthy, 
these local and general changes do not occur. 

My own experience in cases of removal of the ovaries for inflammatory 
conditions, tubal enlargements, and minor ovarian disorders, does not 
coincide with that of Lusk ; I have found that a much larger proportion 
of women continue to menstruate regularly for years after the ovaries have 
been removed, and that the only difference in these patients is that the 



DISORDERS OF MENSTRUATION 347 

menopause is antedated by some years, and that, in most of them, though 
by no means in all, menstruation, if it continue, is without pain. 

In a few cases of this kind, especially those in which the operation 
was undertaken for the cure of fibroids, I have found that the haemor- 
rhage has sometimes been increased. 

Though it is obviously impossible to follow every case to a definite 
issue, the following is my experience in the matter : — 

Removal of the Ovaries and Tubes for Minor Affections. 

100 Cases. In 40 menstruation ceased. 

In 30 ,, continued irregularly for years. 

In 20 ,, ,, regularly. 

In 10 ,, recurred at long intervals. 

Symptoms of Amenorrhoea. — Besides the absence of the periodic flow, 
which is, of course, the chief symptom, numerous constitutional symptoms 
are observed as the accompaniments of amenorrhoea. Thus hysteria is 
frequently an important and serious complication ; while minor sensory 
disturbances, such as amblyopia and tinnitus, may be reflex or the result 
of anaemia. Paresis has also been known to occur, due no doubt to the 
accompanying hysterical condition. 

There is no question that many forms of skin eruption, such as acne, 
pemphigus, erysipelas, herpes, eczema, and urticaria, may accompany 
the suppression of menstruation. Hyperidrosis, too, has been known 
to follow a sudden cessation of the monthly flow. 

Vicarious Menstruation. — Many cases are recorded in which the 
function of menstruation has been taken up by other organs of the body, 
the condition being known as vicarious menstruation. Jones reports a 
most remarkable case in which, when menstruation was suddenly sup- 
pressed by a chill, the woman for five months thereafter had amenorrhoea, 
but regularly in each of these months she had for thirty six hours an 
abundant flow of milk from the breasts. In another case the catamenia 
were replaced by a profuse diarrhoea which lasted for three days every 
month ; and in yet another a periodic leucorrhoea was the only indica- 
tion of the menstrual function. 

Besides these extraordinary cases, many are recorded of haemorrhages 
from the respiratory or alimentary tracts, of epistaxis, haemoptysis, or 
haematemesis replacing the normal uterine discharge. j\Iore rarely 
bleeding from the ear has occurred, and in one or two cases subcutaneous 
haemorrhages have been observed, or a bleeding from a raw surface, such 
as an ulcer, has taken place regularly every month. 

Perhaps a cerebral apoplexy, which occasionally has been known to 
follow the sudden cessation of menstruation at the menopause, or the 
cure of a long-continued haemorrhoidal discharge is to be regarded as an 
event of a like kind. 

Treatment of Amenorrhoea. — This naturally varies very much accord- 
ing to the cause. In many cases it is quite useless to administer drugs 



348 SYSTEM OF GYNECOLOGY 

that are supposed to act directly upon the function of menstruation, 
without first carefully considering whether some general constitutional 
condition may not account for the suppression. No doubt, in some 
cases, such drugs as rue, savin, or saffron, have succeeded in restoring 
the function ; but this result has occurred in cases in which the amen- 
orrhoea was simply due to a chill or violent emotion. When it is the 
result of anaemia, chlorosis, syphilis, or tuberculosis, these diseases rather 
call for treatment, and the pelvic organs require no special attention. 
In amenorrhoea from chlorosis — so common in young girls — treatment 
by iron and arsenic, baths and saline purgatives, is followed by excellent 
results ; but perhaps the most useful way of combating these cases is 
by the persistent use of arsenic, followed by a short course of aloes and 
iron in pills. Many other remedies are attended with equally good 
results. Manganese is considered by some physicians to be as useful as 
iron in the treatment of anaemia ; it is also supposed to have a special 
emmenagogue action : I have not found it nearly so satisfactory as some 
forms of iron. Judicious physical exercise and change of air are also 
important in the treatment of amenorrhoea. 

As regards local treatment, this in many cases is of no avail. When 
the organs have become atrophied from any cause no local treatment 
seems to have much effect in ameliorating the condition. Electricity 
has been advocated by many physicians, and in the hands of some I 
have no doubt it has been occasionally successful ; but my own experi- 
ence of it has not been very encouraging. 

In those instances in which the suppression of menses is due to the 
patient's rapidly growing obesity the indication is clear ; and careful 
dieting, with baths and exercise, will generally effect a cure. Stimula- 
tion of the uterine mucosa by gentle curettage may sometimes be use- 
ful in securing a return of the menstrual flow. 

In the amenorrhoea which results from a premature menopause due 
to the removal of the ovaries, the ordinary symptoms of the climacteric 
period — lumbar pains, flushings, giddiness, and irritability — usually ap- 
pear. In such cases, besides the general treatment by bromides and tonics, 
the patient occasionally derives benefit from scarification of the cervix 
every month so as to obtain a slight local bleeding and relief of congestion. 

The intra-uterine zinc and copper stem pessaries, so much advocated 
long ago by Sir James Simpson, are, I think, devoid of any important 
galvanic action, yet they evidently do good in some cases, as does scari- 
fication of the cervix, by permitting a temporary flow and giving a 
temporary relief. 

Scanty Menstruation. — This condition is due to causes very similar 
to those of amenorrhoea. It may be either primary or acquired. If 
primary it remains constitutional through life; if acquired it is as the 
result of some intercurrent pathological condition, such as those referred 
to in the description of amenorrhoea proper. 

Here, however, it must not be forgotten that scanty menstruation, 
like menorrhagia, is merely a relative term ; menstruation is abnormal 



DISORDERS OF MENSTRUATION 



349 



when it extends beyond six days in the one direction, or is reduced 
to two in the other. It must also be borne in mind that, before any 
opinion can be given, the menstrual habit of the individual must be 
accurately determined. 

The treatment is to be on lines similar to those laid down under the 
head of amenorrhoea. 

In a certain class of cases inflammation which, in the first stage, 
tends to cause menorrhagia, at a later stage induces amenorrhoea. Such 
cases are best illustrated by endometritis. As is well known, the 
symptom of acute and subacute endometritis is menorrhagia; but 
when the condition has become extremely chronic, when the mucous 
membrane has become thin, the vessels shrunk, and the fibrous tissue 
greatly increased, scanty menstruation is a well-marked symptom. This 
condition has also been frequently observed in what is known as para- 
metritis atrophicans, in which, owing to the contraction of an inflamma- 
tory deposit in the broad ligament, the arterial supply to the uterus 
has been so curtailed that scanty menstruation or even amenorrhoea has 
been the natural result. 

Menorrhagia and Metrorrhagia. — By the term menorrhagia is meant 
an excess of discharge occurring at the time of the usual menstrual 
period; by metrorrhagia, haemorrhage from the uterus not coincident 
Avith a menstrual epoch. In considering these two symptoms it is 
necessary, in the first place, to deal with the difficulty of deciding what 
amount of haemorrhage at the monthly period is to be considered as ex- 
cessive ; and in the second place, as all bleeding from the vulva, apart 
from the menstrual flow, might at first be considered as metrorrhagia, the 
causes of bleedings which might wrongly be confused with metrorrhagia 
must be enumerated, in order that we may eliminate them, and find 
ourselves free to deal with the subject systematically. 

Menorrhagia may occur as an excessive flow of blood during the 
normal number of days which constitute a period, or as an ordinary flow 
extending over an excessive number of days. Our only means of 
comparison is to ascertain if the function differs from the patient's usual 
habit, and, moreover, if it is affecting her general health. 

In the case of delicate anaemic girls, ill enough able to sustain the 
nutrition of their own bodies, even an entire absence of menstrual dis- 
charge is not necessarily to be looked upon as an evil ; we may find that 
on the restoration of health by tonic and restorative treatment the 
periodic discharge of blood will take place without reducing the bodily 
powers : on the other hand, there are women who normally menstruate 
for eight or ten days at each period without suffering any inconvenience 
or derangement of the general health. Thus, in a woman who has 
menstruated before, it is only by a consideration of her menstrual habit, 
and by making due allowance for climatic and other influences, that we 
can determine the standard by which her menstruation is to be judged. 

At the same time it is well, for general purposes, to have an arbitrary 



350 SYSTEM OF GYNECOLOGY 

limit ; and this we can roughly assign by observing the average time 
occupied by the period in a considerable number of women — a matter 
already discussed under amenorrhoea : we should thus be led to consider 
the function to be excessive if it lasted longer than six days ; and the 
actual amount of blood lost may be estimated in terms of the diapers 
employed — ten to fifteen being looked upon as a fair average number 
for each period. 

The term metrorrhagia is held to imply only bleedings from the 
uterus and cervix uteri : on the one hand, it is obviously impossible in a 
gynaecological treatise to consider at length hsemorrhages occurring in 
connection with pregnancy ; and, on the other hand, the discussion of 
bleedings from the vagina and vulva belong to other chapters. It is only 
necessary in this place, in order to facilitate reference, that these various 
sources of haemorrhage should be mentioned. 

Bleeding associated with abortion, myxomatous degeneration of the 
chorion, placenta prsevia, separation of the placenta ("Accidental 
Haemorrhage "), retained placenta or membranes, inertia of the uterus, 
and inversion of the uterus, is fully described in works on Obstetrics. 

Of sources of haemorrhage which may be mistaken for menorrhagia 
we may simply mention vaginitis, with ulcerations or other lesions of 
the vagina; injuries of the hymen and vulva; and the rare occurrence 
of rupture of varicose veins in the pudenda, associated especially with 
pregnancy. 

We have next to consider a class of causes which are independent of 
the special function of the uterus, but may produce bleeding from it as 
from any other mucous membrane of the body. These causes depend for 
the most part on alteration in the condition of the blood. For example, 
a woman of the haemorrhagic diathesis will bleed much more profusely at 
her menstrual epoch than other women, as would be the case with her in 
epistaxis, or on the breach of any other surface. Besides haemophilia, 
scorbutus and purpura act in this way ; and although chlorosis, as we 
have found above, tends rather to produce a condition of amenorrhoea 
with leucorrhoea, yet in some cases it leads to menorrhagia and metror- 
rhagia. It may be that in these cases the condition of the blood and the 
state of the vessels is sufficient to account for the haemorrhage ; but some 
local condition is often found along with these, such as a small fibroid 
tumour, or a congested condition of the uterine mucosa due to displace- 
ments, which as well as the general condition require treatment. These 
cases are amongst the most difficult to treat, because they interact in such 
a way as to produce a " vicious pathological circle " — the drain on the 
system by the haemorrhage tending to aggravate the very sj^stemic con- 
dition which in its turn leads to the menorrhagia. 

Many other general conditions dispose to menorrhagia and metror- 
rhagia. Of these are long-continued mental depression, hysteria, and other 
nervous disturbances ; deranged states of the system due to too luxurious 
and too sedentary habits of life ; residence in tropical climates, or in 
damp, unhealthy situations ; malaria ; tubercle ; the acute exanthems 



DISORDERS OF MENSTRUATION 351 

(" uterine epistaxis " associated with, typhoid fever) ; lead and phosphorus 
poisoning, and Bright's disease. 

Haemorrhage, again,may be associatedwith. disorders of thecirculatioii. 
Backward pressure, especially as the result of mitral incompetence or 
stenosis, or a congested condition of the vessels of the pelvis, the result of 
pressure exerted on the veins of the portal system by new growths, is 
apt to produce bleeding, which like the epistaxis that sometimes appears 
to save a patient from a cerebral hsemorrhage, may be looked upon 
as a relief of congestion. In most cases of the kind, however, we may 
suspect the presence of a predisposing local condition in a diseased 
state of the uterine mucous membrane. 

Cirrhosis of the liver and kidneys is a cause belonging to the same 
class ; and when the cirrhosis itself is due to alcoholism we may find a 
threefold cause in hepatic cirrhosis, in a hypertrophied and dilated 
state of the heart, and in a diminished activity of inhibitory nervous 
centres or tracts. 

Such are the chief general conditions which may dispose to or pro- 
duce the disorder ; in discussing the local causes it will be convenient to 
associate these with the three most important epochs in the sexual history 
of woman, which are (i.) puberty, and the early years of menstrual life ; 
(ii.) the period of fertility ; and (iii.) the menopause. 

(1.) Menorrhagia during Puberty and the early years of Menstrual 
Life. — From what has already been said it may be gathered that in young 
girls the causes of menorrhagia are for the most part of a general kind. 
In such cases local examination, except under the most urgent circum- 
stances, is to be avoided ; and treatment ought to be directed to 
the improvement of the general health, and especially to the nervous 
and hsemopoietic systems. If in such cases local examination is indis- 
pensable it should be made by the rectum, unless vaginal examination 
be absolutely imperative. In either case the patient should be anaesthe- 
tised. 

On the occurrence of every menstrual period, a condition of pelvic 
hyperoemia, short of actual inflammation, with its various stages of conges- 
tion, exudation, and resolution or suppuration, is established. In some 
cases this hypersemia is so much exaggerated as to give rise to distressing 
symptoms — especially to menorrhagia — resembling those of acute inflam- 
mation of the uterine appendages. This event is not an uncommon 
result of the reflex irritation which, accompanies the occurrence of the 
first menstrual period, especially in the case of girls who are brought up 
in refinement, and who are overtaxed at school. The fact that local 
irritation may dangerously increase this condition of hypereemia must 
not be overlooked. 

(ii.) Menorrhagia during the period of Fertility. — In cases of this 
class a local cause is more commonly to be found, even if some co- 
existing general condition accentuate the symptoms. In these subjects 
local examination must be promptly considered and unhesitatingly urged: 
haemorrhage is too dangerous a symptom to admit of delay. 



352 SYSTEM OF GYNECOLOGY 

As in the former class of cases pelvic hypercemia is the immediate cause 
of haemorrhage. Local irritation may be found in the first sexual act or 
in excessive indulgence. Too prolonged a lactation acts in the same way, 
and also by lowering the general tone of the system. In these cases, 
unless the cause be removed, the line between mere congestion and active 
inflammatory changes is readily overstepped. 

Fibroid tumours, which are a very common cause of excessive flow, 
probably act likewise — by an increased vascular supply to the uterus, and 
also by the production of an enlarged and inflamed secreting surface : 
thus we find excessive bleeding as a result of all enlargements of the 
uterus from neoplasms and from subinvolution ; and of all inflammatory 
conditions of the peritoneal, muscular, or mucous coats. Uterine dis- 
placements, such as prolapse and flexions, are amongst the commonest 
causes of menorrhagia. 

The excessive haemorrhage in flexions is caused, according to some 
observers, by a temporary accumulation of blood in the cavity of the 
uterus, which causes distension and an increase of the secreting surface. 
As more fluid accumulates during the menstrual period, a gush occurs 
from time to time, so that the patient suffers from alternate retention 
and escape of menstrual blood. A continuously excessive flow of blood 
is rare in such cases : in the great majority menorrhagia occurs in 
gushes. 

Other observers, however, believe that the menorrhagia in cases of 
flexion is simply the result of the endometritis, which they consider to be 
a constant accompaniment of displacements, an opinion with which I 
entirely concur. Those who support the " retention " theory apply it 
also to the causation of the menorrhagia of fibroids. 

Extra-uterine iriflammations, implicating the ovaries and tubes, all give 
rise — except in their final sclerotic stage — if not to metrorrhagia, at 
least tomenorrhagia. Ovarian tumours may have the same effect, although 
not nearly so markedly as uterine tumours ; in fact the growth of many 
ovarian tumours does not affect menstruation at all: yet disturbances 
of the circulation in the ovaries may tend to produce haemorrhage from 
the uterus without apparently affecting the healthy state of this organ. 
Tumours arid cysts in the broad ligaments find a place in the class of causes 
of congestive haemorrhage, because they act by interference with the 
circulation and with the normal position of the uterus. 

Another set of causes are those which directly alter the condition of 
the surface concerned. Endometritis has already been mentioned among 
the inflammations ; but there is a special form of endometritis, known as 
villous, or hmmorrhagic endometritis, which gives rise to profuse haemor- 
rhage, and often simulates primary cancer of the fundus. Cancer both 
of cervix and fundus, polypi, tubercular and other ulcerations, produce 
haemorrhage in great measure because of the changes they effect in the 
mucous membrane, such as erosion of it, and consequent implication of 
the superficial and sometimes even of the deep blood-vessels. 

A small class of cases may be mentioned, mainly consisting, so far as my 



DISORDERS OF MENSTRUATION 353 

experience is concerned, of soft, fat, flabby, anaemic women, whose 
menstruation, so far as sanguineous discharge is concerned, is entirely in 
abeyance, and is replaced by a profuse uterine leucorrhoea. This may be 
as exhausting as profuse haemorrhage, and is often accompanied by 
colicky pains. I have never seen any local treatment to be of any benefit 
in such cases. Careful dieting, exercise, salines, and a course of Marienbad, 
constitute the most satisfactory treatment. 

Idiopatliic Hcemorrhage. — There is one form of haemorrhage not yet 
mentioned which may occur during active menstrual life. It is referred 
to by several authors ; but in these days one would almost hesitate to 
mention it were it not for the occurrence of cases which can be assigned 
to no other class, but must be collected under some such name as Idio- 
pathic Haemorrhage. I am strongly of opinion that it must be extremely 
rare for haemorrhage to occur with no local or general lesion, and yet the 
following case, which came under my observation some years ago, is very 
difiicult to interpret otherwise ; — 

The patient, a married woman with four children, whom I had 
known throughout my whole professional life, had menstruated regularly, 
but rather profusely. When thirtj^-eight years old, six years after the 
birth of her last child, she was seized, during the course of a menstrual 
period, with a uterine haemorrhage so severe that, in the middle of the 
night, I was obliged to plug her vagina. On the occasion of her next 
menstruation the same method had again to be adopted to arrest 
haemorrhage; and this had to be carried out time after time for five 
months, although the usual appropriate intermenstrual treatment by hot 
douching, ergot, etc., was strenuously persisted in; and on two occasions 
her uterus was curetted and styptics applied to the bleeding surface. 
Each successive menstrual period left her more and more exhausted. 
She was examined frequently, with the utmost care, under chloroform ; 
but no local lesion whatever, nor any general condition could be found 
to account for this excessive flow. I am well aware that even the 
smallest polypi may cause profuse and even fatal haemorrhage ; but in 
this case, after dilatation of the cavity of the uterus and the most careful 
examination, I could find no trace of any such thing. 

During the course of a menstrual period the patient died, apparently 
of syncope. 

An autopsy was conducted by Dr. Sims Woodhead. The uterus 
was examined minutely, yet, except that it was slightly enlarged — 
to the extent of 3 inches — and contained a clot, no morbid condition 
was found at all. There was no neoplasm, nor any abnormality whatever 
in any of the coats of the uterus. In the left ovary there was a large 
corpus luteum. The thoracic and abdominal viscera Avere pronounced 
to be normal. The symptom in this case might have been attributed to 
haemophilia: but. as the woman had presented no other indications of this 
condition either in her earlier or her later life, and as in her family history 
there was nothing to suggest such a diathesis, there was no course open 
but to suppose the case to be one of "Idiopathic Menorrhagia." 

2 a 



354 SYSTEM OF GYNECOLOGY 

(iii.) Menorrhagia at the time of the Menopause. — The menopause 
is a period which is characterised by the occurrence of haemorrhages. 

The climacteric may manifest itself in three special ways : (a) the 
menses may cease gradually ; (6) they may cease only after a long-con- 
tinued series of haemorrhages ; (c) they may cease suddenly. 

It is with the second of these varieties that we are more especially 
concerned at present. Whenever at the menopause haemorrhages are 
profuse very careful local examination should be made, in order to 
ascertain whether the condition be due to the presence of a neoplasm, 
to some other local cause, or to general causes. A most important point 
to notice is that, after the menopause has once become established, post- 
climacteric haemorrhages are almost invariably due to a local lesion, such 
as senile catarrh, cancer, or the presence of mucous or fibrous polypi ; 
though cases are recorded in which this symptom has been due to sexual 
excitement. But it must always be kept in mind that women of a gouty 
diathesis not only often menstruate very late in life, but have recurrent 
post-climacteric discharge due to this dyscrasia. 

This is not the place in which to discuss the differential diagnosis of 
cancer from senile uterine catarrh or fungous granulations on the uterine 
mucosa ; but the importance of establishing a certain diagnosis, and of not 
postponing a local examination till it is too late, cannot be too strongly 
urged. 

The above discussion of uterine haemorrhage shows, at least, the 
importance of regarding it rather as a sign than as a disease. While 
on the one hand the cause of the bleeding in each case must be carefully 
sought out, we shall remember on the other hand that in young unmarried 
women the most common causes of menorrhagia and metrorrhagia are 
constitutional; in fertile women, subinvolution, fibroids, and displace- 
ments of the uterus ; in single middle-aged women, fibroids ; and in 
women between forty and fifty, either the usual climacteric haemor- 
rhages or cancer or fibroids. 

The symptoms of menorrhagia are, of course, the symptoms and 
signs of loss of blood from any part. It may occur suddenly and 
compromise the patient's health rapidly ; or it may occur gradually in 
increasing quantity month by month, and thus induce anaemia with its 
consequent results. 

The haemorrhage of a so-called haematocele might, no doubt, be 
described with some truth as an internal menorrhagia. More commonly, 
however, there is an external as well as an internal haemorrhage ; and as 
haematocele is now regarded as being, in the great majority of cases, due 
to an early ruptured extra-uterine gestation, it is not necessary to discuss 
the subject here. 

Treatment. — It will be evident from the great diversity of causes 
that the -treatment of the symptoms under consideration must have a 
direct reference to the cause, and cannot be indicated on general lines to 
suit all cases. 

As we have to decide in amenorrhoea whether it be advisable or not 



DISORDERS OF MENSTRUATION 355 

to bring about the haemorrhage which is in abeyance, so in menorrhagia 
it is frequently not without benefit to the patient that she should lose 
more blood than usual, or even that blood should flow at an abnormal 
time, so long as the loss of blood does not markedly depress her general 
health. WJiere salpingitis or ovaritis or other inflammatory condition 
exists which produces congestion in the structures about the uterus, 
the local loss of blood may often relieve the pain and reduce the con- 
gestive condition. So, as mentioned above, in cases of backward pressure 
producing congestion, bleeding from the uterus may prevent congestion 
or bleeding at parts where it would be much more dangerous. 

The treatment of the general systemic conditions which were first 
discussed obviously consists in measures tending to the improvement of 
the general tone. E-est in bed at the time of the flow is frequently 
advisable ; because, apart from the fact that less blood is likely to be lost 
by a patient lying on her back with the hips raised than if moving about 
in the ordinary way, it is also the case that a patient lying still, with the 
head low, can lose more blood with less bodily harm accruing from the 
loss. 

It is by such a plan as this that the menorrhagia of young girls must 
be treated before we resort to such means as the hot douche, or indeed to 
any local treatment. Mental and bodily rest, with careful feeding, are 
essential; and so is the administration of salines and tonic medicines. 
The following prescription is so commonly used in my ward that it goes 
by the name of '' The Ward Mixture " — I^ Magnes. sulph. 3ss.-3j., Quininse 
sulph. gr. iss., Ferri sulphat. gr. v.. Acid sulphuric dil. Tn.x., Aq. menth. 
pip. ad _5j. 

But it must be further remembered that very often in cases where the 
condition may seem to be due to general causes, there exists also a local 
lesion in the mucosa, which may be the subject of fungoid granulations. 
In such cases curetting is often of great avail. This operation, one of 
no great difficulty, is described at length in another part of this work 
{vide p. 292, et seq.). 

Curetting will be found of great service in most cases of menorrhagia 
and metrorrhagia. Some authors, indeed, recommend its employment 
even in cases where in the actual state of the mucosa it does not appear 
to be required ; in cases, for instance, where the haemorrhage is apparently 
due to nothing more than an inflamed condition of the ovaries. 

With regard to general means of checking haemorrhage it has been 
found that not much is to be gained by the internal administration of 
drugs. Out of a very large number of drugs which have the reputation 
of haemostatics but very few can be relied upon: of these the foremost 
is undoubtedly ergot. It acts by causing contraction of non-striped 
muscle, and thus diminishing the calibre of blood-vessels : in the uterus, 
moreover, it causes contraction of the network of muscular fibres which 
form the middle coat, and constricts the vessels which pass through that 
network ; but, so far as my experience goes, ergot acts very inefliciently 
on the uterus except when the muscular tissue is hypertrophied, as after 



356 SYSTEM OF GYNAECOLOGY 

labour or abortion ; or in cases of fibroid. Ergotine, especially in con- 
junction with strychnine or nux vomica, is perhaps the most efficient 
preparation. Hydrastis alone or with ergot is often of service. 

Apart from its use in abortion or parturition, the administration of 
the drug must be long continued in order to be of any benefit. Sulphuric 
acid and cannabis indica are undoubtedly useful also in certain cases. 

The investigations of Dr. Wright of IsTetley give promise of a new 
remedy applicable in certain cases of menorrhagia and metrorrhagia, 
namely, calcium chloride. The chloride is a convenient salt of calcium, 
because it is readily soluble in water ; and calcium acts by increasing the 
coagulability of the blood. In cases, therefore, where the coagulability 
of the blood is less than normal (and Dr. Wright describes a clinical 
method of estimating this), the internal administration of the chloride of 
calcium in doses of gr. xv. would act beneficially by bringing the coagu- 
lability up to the normal point. It has been tried in cases of uterine 
haemorrhage, and certainly has produced good results in some of them, 
both as a draught and as a local application. 

Of local applications none can bear comparison with the use of hot 
water applied in the form of vaginal douches at a temperature of 120° F. 
Indeed, there is no better method of checking a long-continued menstru- 
ation than to douche the patient regularly with hot water. Many 
women object to the practice ; but it is, nevertheless, a perfectly safe 
and satisfactory way of stopping a long-continued menstrual discharge. 
Experiments on the uterus in some of the lower animals have proved 
that hot water as a muscular stimulant is much more beneficial than 
cold. The contraction produced by hot water is more rapid, and, what 
is more important, it is continued for a longer time than that produced 
by cold. Moreover, it must be obvious that the effect of a hot applica- 
tion on the system must be much better than that of one which re- 
moves a considerable amount of heat from a body already reduced by 
loss of blood. 

The local application of styptics, especially by means of Playfair's 
probe covered with cotton wool and dipped in some astringent solution, 
is often of the utmost value, even without any previous curettage. 

Plugging of the vagina with damp antiseptic wool is often most ser- 
viceable ; in exceptional cases the uterus may be packed with antiseptic 
gauze. It has been said that this packing may result in a dangerous 
regurgitation of fluid through the Fallopian tubes; but this event, 
so far as I know, is extremely rare, and, if it does occur, is not associated 
with any serious symptoms. Plugging is a good temporary method of 
checking haemorrhage, and gives time for the application of measures to 
restore the patient's strength, and for the adoption of more permanent 
remedial means. 

Electricity. — The constant current in the treatment of menorrhagia 
seems to me to have a specially beneficial effect in those haemorrhages 
which occur at or near the menopause, when the uterus is undergoing 
atrophic changes. It is also useful in the subinvolutions of actively 



DISORDERS OF MENSTRUATION 357 

fertile women — although I am obliged to add that in two cases thus 
treated subinvolution fell into superinvolution, with subsequent perma- 
nent sterility. In these cases, therefore, this method of treatment must 
be carried out with special precautions. It is not part of my duty 
in this article to pronounce upon the effects of the continuous current 
in the treatment of fibroids, but I may say that in specially selected 
cases of small fibroids, and of hsemorrhagic endometritis, this method 
of treatment, if carried out with care and by competent hands, frequently 
effects a temporary and occasionally a permanent cure \yide art. "Elec- 
tricity in Gynaecology "]. 

Removal of the Ovaries. — As regards the treatment of menorrhagia, 
apart from any uterine neoplasm or general condition, by removal of the 
ovaries, I will give here the reports of two cases : — 

1. A girl, twenty years of age, unmarried, suffered for three years 
from haemorrhage to such an extent as to render her a complete invalid. 
When she came under my observation her menstrual flow lasted for 
fourteen days. At the end of her period she was bloodless, and subject 
to frequent faints. The uterus was curetted, and she was put under 
long courses of styptics and douching, with little if any benefit. As a 
last resource removal of the ovaries was considered and ultimately carried 
out. She has never menstruated since, and is now a staff nurse in a 
hospital in the enjoyment of perfect health. 

In this case the ovaries, although somewhat enlarged and heavy, 
were not the subjects of any cystic or other degeneration, and the cause 
of her uterine haemorrhage was not otherwise apparent. 

2. Another case occurred of a somewhat similar character. A young 
lady of twenty-five had been married for four years, and was sterile. She 
bled so profusely at her periods, and occasionally intermenstrually, that 
she was practically bedridden. The uterus was apparently normal. She 
had no general disorder, and after the usual treatment by curetting, 
styptics, and hot douching for a long time, no improvement resulted. 
After careful consultation, and with the concurrence, of course, of her 
friends, the ovaries were removed. Since that time, ten years ago, 
menstruation has not returned, and she has been in the enjoyment of 
excellent health. The ovaries, as in the former case, were simply en- 
larged and heavy. 

In neither of these cases was there any reason to suppose that any 
sexual irritation existed. Now, although I am very far from recommend- 
ing such a course for frequent adoption, I mention these cases as extreme 
ones, needing extreme measures. No operation in gynaecology requires 
to be more safeguarded than that for removal of the ovaries. It is, 
unfortunately, an easy operation, and one far too frequently performed. 
I mention the above cases only as exceptional ones. 

The treatment of uterine displacements, cancer, fibroids, and all 
other local conditions which give rise to haemorrhage, must be sought 
for in other parts of the System. __ 



358 SYSTEM OF GYNECOLOGY 

Dysmenorrhcea. — All women, even while enjoying good health, feel 
" unwell," as they themselves call it, at the menstrual period. They ex- 
perience some pelvic discomfort or inconvenience associated with a general 
malaise, a few indefinite pains in the back and loins, and a certain irrita- 
bility of temper ; that a woman should not be thus affected would be almost 
an abnormality. However, I do not for a moment deny that some women 
menstruate with no trace of suffering whatever, the presence of the 
discharge being only an inconvenience. It is easy to understand the 
''normal" discomfort if the nature of the function of menstruation is 
considered. It is impossible to suppose that the various changes, 
especially the congestion, which occur during the different stages of the 
process of normal menstruation should take place without giving rise to 
a certain amount of pelvic and general discomfort. But the difficulty 
lies in fairly estimating the suffering of the individual, and in determin- 
ing when the disorder has ceased to be physiological and has become 
pathological. The sensitiveness of the nervous system in women varies 
so much that what is described by some as an " inconvenience " by others 
is called "discomfort"; what is to some "discomfort" to others is 
" pain " ; and yet others, again, who call their suffering " a little pain " 
endure as much as many who describe their sufferings as " agonising " or 
" excruciating." One must, therefore, draw a line of demarcation between 
the mere discomfort of m enstruation — no matter howit is described by the 
sufferer — and genuine dysmenorrhoea, which is graver pain occurring at 
or about the menstrual epoch ; pain so severe as to interfere with health, 
with work, or with pleasure. It is not easy to lay down a hard and fast 
rule in the estimation of pain, which, after all, is a symptom which does 
not directly appeal to any of the senses of the physician. With limita- 
tions, however, it may be concluded, in the case of a poor woman who 
has to work for her daily bread, that if her dysmenorrhoea is not suffi- 
cient to lay her up and so to withdraw her from her duties, then her 
suffering requires no special local treatment; in the well to do, if 
the pain does not deprive the sufferer of her social enjoyments and 
amusements, it likewise calls for no special local treatment. In these 
cases even a vaginal examination, at any rate in the unmarried, should 
not be undertaken, or at all events not without a prolonged trial of general 
remedies and management. But there is no doubt a very large number 
of women who constantly demand and deserve our attention on account of 
menstrual suffering. Their pain is not the mere discomfort of all women, 
nor the temporary severe pain of many, but a prolonged agony ; in some 
cases so extreme as to render life a burden for years. No sooner has the 
pain of one epoch passed than they begin to dread with horror the next ; 
and so life is rendered miserable. The disease, or rather the symptom, 
seldom leads directly to death ; but it does interfere to a very large extent 
with fertility, health, and happiness. With such a state of things one 
has frequently to deal in practice, perhaps more frequently than with 
any other disorder of menstruation ; and, further, the reflex and sympa- 
thetic disorders associated with dysmenorrhoea — the mental and nervous 



DISORDERS OF MENSTRUATION 359 

derangements — are many. These neuroses, due mainly to changes in 
the ovaries, are well recognised, and must be carefully considered in 
dealing with d3^smenorrhoea. 

There is no very definite relation between the amount of flow and 
the degree of dysmenorrhoea : although in many of the spasmodic and 
membranous forms, as we shall see further on, the discharge is often 
scanty, yet it is often profuse in the ovarian and tubal forms, in both of 
which the pain is equally well marked. Perhaps, on the whole, uterine 
dysmenorrhoea is more marked when the menstruation is scanty than 
when it is profuse. 

In some women the dysmenorrhoea begins with puberty and, unless 
active treatment is adopted or pregnancy occurs, it continues all through 
adult life : in others it arises only after some distinct exciting cause, 
such as a chill, or under conditions which give rise to inflammatory or 
other changes in the uterus or its appendages. No doubt dysmenorrhoea 
is commoner among unmarried women, but sometimes it sets in only 
after marriage. When met with in married women it is frequently 
associated with sterility ; and it is certainly less frequent among parous 
women than in the nulliparous. 

DysmenorrhcEa and Sterility. — Some relation between dysmenorrhoea 
and sterility has been observed frequently enough. In many cases the 
association is accidental. So far, indeed, as I am able to judge, the 
association of dysmenorrhoea with sterility is not so close as is generally 
supposed. 

Kehrer, who has gone into this matter at some length, has shown 
that a history of painful menstruation before marriage is only slightly 
more common in sterile than in fertile women. Kammerer gives a table of 
408 cases of sterility, in 67 of which dysmenorrhoea was a prominent symp- 
tom ; Jackson gives a table of 72 cases of sterility, in 16 of which dys- 
menorrhoea was a prominent symptom. Certainly, on reflecting upon 
my own experience, I should not be inclined to give dysmenorrhoea a 
prominent place in relation to sterility. Obstructive dysmenorrhoea, 
putting the term conversely, and regarding various conditions of the 
uterus as obstacles to conception, scarcely appears to me to have any 
foundation : in fact, as Jackson says, " The obstacles which are over- 
come by spermatozoa in their progress towards the uterine cavity are, 
to say the least, remarkable." 

The view which commends itself to me is that, in cases of dysmenor- 
rhoea associated with sterility, the explanation of both conditions is to be 
sought for rather in general congestion of the pelvic organs, more espe- 
cially of the endometrium, than in any mechanical cause. The dys- 
menorrhoea is accounted for by a hypersemia ; and the sterility, not by 
any mechanical interference with conception, but rather by some con- 
dition of the endometrium which interferes with the continuance of 
gestation. In other words, the dysmenorrhoea is due to congestion of 
the uterus associated at times with spasm of the os uteri internum ; and 
the sterility to a hyperaemic and hypersesthetic state of the endometrium. 



36o SYSTEM OF GYNAECOLOGY 

Such a view as this explains how it is that, after treating various 
conditions of apparent mechanical obstruction — such as anteflexion, 
stenosis, and so on — the sterility continues. A very large number of 
the processes concerned in generation are, no doubt, wholly mechanical ; 
and it is not surprising, therefore, that in cases of sterility which present 
some apparent obstacle of a mechanical character, this obstacle should 
be promptly accepted as the efficient cause, and mechanical means adopted 
for its relief. It is certain that the cure of an anteflexion or a retro- 
flexion, or in other words the removal of causes apparently mechanical, 
has resulted in the cure of dysmenorrhoea ; and we have learned clini- 
cally that it has sometimes been followed by a pregnancy. Far oftener, 
however, these mechanical means, while relieving the dysmenorrhoea, 
have failed entirely to remove the sterility, — failed, no doubt, because 
they did not remove some condition other than the mere narrowing of 
the cervical canal ; such a condition seems to me to be a morbidly 
hypersemic state of the endometrium, which renders the grafting of the 
ovule an impossibility. 

The Varieties of Dysmenorrhoea. — The classifications given by differ- 
ent authors are endless, but many of them have been framed upon erro- 
neous notions of the nature, firstly, of menstruation, and, secondly, of 
dysmenorrhoea. For example, many arrangements have been suggested 
on a purely mechanical or obstructive view of the causation — as if due 
to displacements, stenosis of the cervix, and so on ; and while these are, 
no doubt, elements in the causation, yet some deeper cause underlying it 
all, underlying all the varieties and forms, must be looked for. The 
initial difficulty in discussing dysmenorrhoea lies in our ignorance of the 
ordinary physiology of menstruation. I cannot here discuss the various 
theories of menstruation, they must be sought elsewhere; but I may 
say briefly that in all varieties, no matter where the exact origin of 
the pain may be, the essence of dysmenorrhoea is congestion. 

It is easy to make a primary classification of the varieties of dysmen- 
orrhoea — one which probably no one will dispute — namely, to divide 
the various forms, clinically, into (I.) Uterine ; (II.) Extra-uterine. This 
classification is based upon a clinical consideration of the nature of the 
pain, and of the organs primarily affected. 

Others have classified the varieties as primary and. acquired ; and this 
arrangement no doubt is occasionally useful. Primary dysmenorrhoea 
is that form which sets in at early puberty and continues into adult life. 
It is found associated Avith defective development, and leads subse- 
quently to the spasmodic form of dysmenorrhoea. Acquired dysmenor- 
rhoea is found in young women after attacks of the exanthemata, or 
after chills ; in parous women it follows sepsis after an abortion or a 
full term labour, and so on. 

It is not now matter for dispute that a uterine and an extra-uterine 
form of dysmenorrhoea exist; but difficulties arise as we recognise that 
the varieties are very often mixed ; and still greater difficulties are met 
with when we attempt to arrange the different causes, especially of uter- 
ine dysmenorrhoea. The difficulty, however, does not lie in the clinical 



DISORDERS OF MENSTRUATION 361 

distinction of the forms, but rather in the proper naming of each kind. 
Different minds are apt to associate different meanings with the same 
word, and hence confusion arises. 

Four factors, roughly speaking, are concerned in the production of 
dysmenorrhoea : 1st, Some morbid condition in the shedding off of the 
mucous membrane in whole or in part, seen in its most pronounced form 
in membranous dysmenorrhoea. In a state of health the process of dis- 
integration, I apprehend, takes place with little trouble ; but if, on the 
other hand, from some such cause as the changes produced in the mucous 
membrane by long-standing inflammation, the process be retarded, centres 
may be furnished for the formation of clots ; and these increasing in size 
and becoming foreign bodies, lead to violent intermittent contractions. 
2nd, The consequent difficulty and pain of the uterine contraction ; which 
are still more marked if the uterine muscle be the seat of any inflam- 
matory change. 3rd, Some obstruction to the outflow of the uterine 
discharge, leading subsequently to retention and congestion. 4th, and 
lastly, these local conditions, themselves a source of local pain and 
discomfort, may be aggravated in each individual case, according to the 
nervous constitution of the sufferer. In other words, the whole condition 
is one of hypersemia and hypersesthesia. 

I. Uterine Dysmenorrhoea. — A. From defective development and obstruc- 
tion. — The first class of cases of uterine dysmenorrhoea to which I would 
refer is that associated with defective development. The uterus after 
puberty in such cases continues in a more or less infantile condition : 
such a uterus is frequently found in young chlorotic girls, and it is 
associated with a marked form of dysmenorrhoea. An undeveloped organ 
performs its function badly, and the uterus is no exception to the rule. 
Ill development has been specially studied by Sir John Williams, and the 
connection between this condition and dysmenorrhoea has been particu- 
larly emphasised. It has further been pointed out that the younger the 
sufferer from painful menstruation the more defective the development 
of the pelvic organs. 

Into this class of cases we may fairly admit the dysmenorrhoea of 
young women who suffer from a displacement, especially from anteflexion 
of the uterus. The position is, however, nothing more than the per- 
sistence of the normal condition of the child ; in short, it is a defect of 
development. This unripeness of the uterus may show itself in other 
ways than in a flexion of the body on the cervix. Frequently stenosis 
of the OS is an indication of ill development ; and when either a flexion 
or a stenosis, or both exist, dysmenorrhoea, frequently called obstructive 
or mechanical, is the most prominent symptom of the existing con- 
dition. But while not denying the possibility of a purely obstructive 
dysmenorrhoea from narrowing of either os, or of the whole cervical 
canal, I venture to say that uncomplicated cases are very rare. Mechani- 
cal obstruction causing pain is possible at the beginning of menstrual 
life ; but ere long a secondary congestion, and even actual inflammatory 
changes from retention of menstrual flow, are an inevitable result. 



362 SYSTEM OF GYNECOLOGY ' 

There are many objections to the "mechanical theory" of dysmenor- 
rhoea. It has been urged that if blood can flow through a capillary tube 
no OS or cervical canal, however narrowly contracted, can offer a positive 
obstruction ; and it is further pointed out that many women with most 
marked flexion and a pin hole os menstruate with no abnormal dis- 
comfort. These and other objections are no doubt potent in many cases, 
and I believe that, in a case of any standing, an inflammatory condition 
must be superadded to the obstruction ; so that most of these cases would 
be grouped in the second class of uterine dysmenorrhoea to be mentioned 
later. I do not wish it to be supposed that cases are frequent in which 
the only signs to account for the dysmenorrhoea are a flexion or a 
stenosis without any indication of excessive congestion or inflamma- 
tion to account for the symptom. The chief symptom of congenital 
anteflexion is undoubtedly dysmenorrhoea characterised by violent pains 
in the loins while the blood distends the body of the uterus — the part, 
that is, above the point of flexion ; suddenly the obstacle is overcome 
and the collected menses, partly fluid and partly in clots, are expelled. 
The purely mechanical theory of dysmenorrhoea, since it was made 
known by Simpson and Sims, has been accepted by most authors. It 
is rejected, however, by Champneys and by Fritsch ; the latter explains 
the pain as due to irritation from congestion ; the abnormal vascular 
tension, the result of the interference with the circulation in the vessels 
at the point of flexion, irritates the nerves of the uterus and so causes 
the pain. However, the paroxysmal and alternating character, both 
of the pains and of the discharge, almost compel one to consider the 
obstruction to an easy flow as of vital importance. 

It has even been suggested that, as the result of anteflexion and con- 
sequent obstruction, a few drops of blood are every month forced along 
the Fallopian tubes into the peritoneal cavity, and give rise to a periodic 
and miniature haematocele. These small internal haemorrhages are con- 
sidered by some observers to be the cause of the posterior perimetritis 
which sometimes accompanies anteflexions ; and this inflammatory con- 
dition would account for the acute febrile phenomena with which the 
dysmenorrhoea of anteflexion is sometimes associated. 

B. Spasmodic and Inflammatory. — Cases in the previous group, as 
age advances, frequently merge into a second class of uterine dysmenor- 
rhoea, namely, the spasmodic and inflammatory. 

The continuance of the mechanical form leads, sooner or later, to 
hypersemia and thence to subacute inflammation; thus the so-called 
" spasmodic dysmenorrhoea " is established. This very well recognised 
form of dysmenorrhoea is the result of spasm, not only of the uterus, but 
of the OS internum, occurring in an organ subacutely inflamed. Whether 
the subacute inflammation be due to the retention of clots in a displaced 
uterus, which act as foreign bodies and cause congestion and spasm ; or 
whether it be due to an alteration in the circulation of the uterus caused 
by the flexion, is a matter which scarcely admits of definite settlement. 
Though this form may sometimes be primary, due to any cause which 



DISORDERS OF MENSTRUATION 363 



may lead to accidental congestion or inflammation of the uterus, it is, 
as we have seen, usually secondary to a dysmenorrhoea, arising from 
defective development or simple obstruction. 

The dysmenorrhoea associated with fibroid tumours of the uterus may 
also be included m this class. Xo doubt many of these cases may be 
attributed to the obstruction which the tumour offers to the easy escape 
of blood ; but in most of them the inflamed condition of the uterine 
mucosa which invariably accompanies the neoplasm is the cause of the 
suffering. 

Many describe as "constitutional" a gouty, a rheumatic, and a 
neuralgic form of menstrual pain. But all these, I believe, are associated 
at least with congestion of the uterus, and many with a marked sub- 
acute form of inflammation ; they are therefore included in the present 
class. The dysmenorrhoea in such cases is simply the evidence of an 
inflammation similiar to that which occurs in other organs of those who 
are the subjects of such diatheses. That this kind of dysmenorrhoea is 
common there can be no reasonable doubt. How else are we to 
account for the persistence of dysmenorrhoea in members of the same 
family ? How else are we to account for the persistence of sterility 
associated with dysmenorrhoea in members of the same family ? I have 
frequently seen families in which the daughters were all dysmenorrhoeic 
and all sterile. Now in such families I believe that the dysmenorrhoea 
is due to gouty or rheumatic inflammation of the endometrium, with a 
resulting spasm of the os uteri internum ; and that the sterility is due, 
not to interference with conception, but rather to the congestion of 
the mucous membrane which thus forms a bad nidus for gestation. 

Symptoms. — The situation of the pain is usually in the neighbour- 
hood of the pubes. The pain is described by the sufferer as " bearing 
down," and comes on in spasms, intermittently. It resembles colic of a 
severe type. The pain lasts for the first day, and, indeed, until the dis- 
charge is distinctly established, when relief is obtained. The actual flow 
may be scanty, but it is generally accompanied by clots. The severity of 
the pain varies ; it is sometimes so severe as to be associated with nausea, 
vomiting, and utter prostration. Occasionally the suffering recurs on the 
second or third day, owing no doubt to the attempts of the uterus to 
expel accumulated clots. 

Spasmodic dysmenorrhoea has no tendency to spontaneous cure, but, 
unless the patient be subjected to appropriate treatment or become 
pregnant, it becomes more and more aggravated as time goes on. When 
pregnancy does occur, and goes on to full term, the patient is usually 
cured. 

Tlie diagnosis of these cases must be accurately made, because upon 
accurate diagnosis depends efficient treatment. 

Of course it occasionally happens that a spasmodic dysmenorrhoea is 
associated with other kinds ; but when the condition is simple it is to 
be recognised : 1st, By the fact that the pain occurs in the first twenty- 
four or forty-eight hours of the menstrual period ; 2nd, that there is no 



364 SYSTEM OF GYNECOLOGY 

appreciable change in the uterine appendages ; and, 3rd, that the uterus 
is freely movable, and usually flexed either anteriorly or posteriorly. 
When such a state of things is ascertained, treatment is satisfactory. 

Treatment. — This resolves itself into — 1. Palliative, which applies 
to all forms of dysmenorrhcea ; 2. Radical. 

1. Palliative Treatment. — This consists, first of all, in dealing with 
any general condition, such as anaemia, gout, or rheumatism, — mala- 
dies to be treated by iron and arsenic, colchicum, and the salicylates 
respectively. In the second place, the treatment of the actual pain 
is to be conducted first of all, and mainly, by pelvic depletion. 
Anything that depletes the pelvis proportionately diminishes the 
hypersemia upon which the pain depends ; and, therefore, the free use of 
salines before the periods is of the utmost value. Very often, in anaemic 
women, a continued use of chlorate of potash, iron, and actsea racemosa, 
used in combination for a week before and during the period, will give 
much relief. 

For the actual suffering, antipyrin, phenacetin, and the other coal tar 
derivatives of this group, will be of service ; Pulsatilla, also, either as the 
tincture in five minim doses every hour, or combined with caulophyllin, 
is most useful ; in my experience it has been eminently satisfactory. 
When the pain is excessive nitrite of amyl or nitro-glycerine may be 
administered with advantage. 

Such peripheral sedatives as cicuta verrosa and castor are useful. 
Undoubtedly opium and alcohol give the most prompt and efficient 
relief ; but their temporary employment may become a permanent habit, 
and therefore they are to be employed with the utmost caution. 
Diaphoretics, warm hip baths, sinapisms, and hot drinks will all relieve 
the distress to a certain extent. 

2. Radical Treatment. — In cases of defective development in young 
girls nothing beyond palliative treatment is to be attempted. But when 
the case is obstructive, or primarily or secondarily spasmodic, then the 
local treatment is clear and definite ; and, as a rule, if undertaken 
carefully, is entirely satisfactory. If the manipulations to be described 
are carried out with careful and antiseptic precautions, and there be no 
peri-uterine disturbance, an absolute cure can in most cases be anticipated. 

In dealing with a case of spasmodic dysmenorrhcea which resists the 
ordinary palliative treatment, and where the symptoms are sufficiently 
severe, a vaginal examination ought to be made under chloroform ; if the 
uterus be found freely movable — anteflexed or retroflexed as the case may 
be — and the uterine appendages healthy, the indications for treatment are 
obvious. There are several alternative means : the first and best is as 
follows. Under anaesthesia the cervix, fixed by a volsella, should be 
gradually dilated by a series of bougies, either metallic ones or those 
of Hegar; in a few cases the mere passage of the uterine sound 
immediately before a period is sufficient to relieve the pain. Secondly, 
as an alternative, the cervix may be rapidly dilated by Sims' or Ellinger's 
dilators. Either of these methods will in most cases be found satisfactory. 



DISORDERS OF MENSTRUATION 365 

The operation, however, has to be repeated frequently. Thirdly, if the 
flexion backwards or forwards be very acute, a stem pessary may be 
found useful. I am well aware of the risk of using these instruments, 
but, with due care and precaution, excellent results may be obtained, 
even in some persistent cases. 

It is essential that immediately after the introduction of the intra- 
uterine pessary the patient should be kept in bed and carefully observed 
for some days. As a rule the introduction is speedily followed by spas- 
modic pains in the uterus, but these soon subside. Occasionally, however, 
a more serious pain results, that of pelvic peritonitis ; and should there 
be the slightest indication of this the stem should be removed instantly. 
It is almost impossible to determine beforehand whether a uterus will 
tolerate the introduction of a foreign body. Some wombs are extremely 
tolerant, others will not endure the slightest mechanical interference 
without inflammatory reaction. Before one ventures to use a stem 
pessary it should be determined that the uterine appendages are per- 
fectly healthy ; the personal equation of the uterus also should be esti- 
mated, so far as x^ossible, by the frequent passage of the sound. If the 
stem pessary can be worn without discomfort, the patient may get up 
after a few days, and after a week or two a larger stem may be substi- 
tuted. The cases which, as a rule, are most satisfactorily treated by 
this method are those of aggravated congenital flexion. The patient 
should not be subjected to the risk of a stem pessary until all other 
means have failed, and then only Avith the utmost caution. 

One other method of treatment of this form of dysmenorrhoea 
remains ; but it may be dealt with shortly, as within recent years it 
has fallen into desuetude, at any rate in this country. 

Sir James Simpson was the first to advocate the division of the cervix; 
and he was led to adopt this method by the common observation that 
dysmenorrhoea is much less frequent in parous women than in the nulli- 
parous. Acting on the supposition that the shape of the cervical canal 
is important in the causation of the menstrual pain, he so divided the 
lips of the cervix that its condition in a non-parous ^voman approximated 
to that of one who had borne children. The operation is performed with 
the metrotome or with Kilchenmeister's scissors. 

Sometimes the operation, instead of being a bilateral one as advo- 
cated by Simpson, is single; and either posterior or anterior according 
to the flexion : the object in view being to straighten the canal distorted 
by the displacement. But the operation of division of the cervix is by 
no means a safe one. Putting aside the risk of sepsis, the hsemorrhage 
is frequently most alarming, so much so that if it is to be performed, 
previous ligation of uterine arteries, or at least of the lower branches, 
is now considered necessary. Very few operators, however, now em- 
ploy the method. 

For the treatment of uterine dysmenorrhoea hy electricity, the reader 
is referred to the article by Dr. Milne Murray in another part of this 
work. The third form of uterine dysmenorrhoea is that known as — 



366 SYSTEM OF GYNECOLOGY 

C. Membranous Dysmenorrhoea. — Morgagni (23) first noticed a kind 
of dysmenorrhoea in which at each menstrual period, or at every second, 
third, or fourth period, a distinct membrane is shed from the uterus dur- 
ing the flow which is accompanied by severe dysmenorrhoea. If one 
accepts the desquamation theory of Sir John Williams, membranous 
dysmenorrhoea is easily explained ; and, similarly, if the hypothesis of 
Englemann be correct — that during menstruation a proliferated mucous 
membrane is shed — then Ave can say that membranous dysmenorrhoea 
is merely an exaggeration of a normal process, and that the membrane 
is discharged in mass instead of in minute particles. 

This curious affection was formerly supposed to be inflammatory ; and 
the shed membrane was compared to the inflammatory exudation cast off 
from the respiratory passages during an attack of croup. But for many 
years it has been known that we have to deal not with an inflammatory 
exudation, but with an exfoliation of the mucous membrane of the uterus. 
This resembles the early decidua in every respect and, like it, is a tri- 
angular-shaped sac with three openings, rough and irregular on the outer 
surface, smooth on the interior. Examined microscopically, the membrane 
possesses the complex structure of an hypertrophied endometrium, and 
contains follicles, nucleated cells, and blood-vessels. Sometimes the 
membranous sac is cast off entire, but more commonly it is shed in 
pieces. Occasionally only the superficial layers of the mucous membrane 
are cast off ; much more commonly the membrane is thick, and represents 
the whole thickness of the hypertrophied and swollen endometrium. 

Virchow says that, on examining the uterus after death in women who 
have died while suffering from dysmenorrhoea, he has found the mucous 
membrane in process of separation. Wylie says that if it be accepted 
that a cellular disintegration takes place during normal menstruation, 
it is possible to imagine that if this degeneration take place. in the deeper 
layers of the mucous membrane, before the breaking down of the more 
superficial layers, these latter might be thrown off as a membrane. 

It would appear that the membrane expelled belongs to, or is the 
product of the former menstrual period. If normally the mucous 
membrane is thrown off during the latter days of the flow, it would seem 
that in these cases of membranous dysmenorrhoea the exfoliation is post- 
poned ; and the membrane continues to grow during the intermenstrual 
period. 

Hausmann adopted the view that these membranes are early 
abortions ; but, although the membrane is not distinguishable from 
decidua, the repeated occurrence and the absence of the villi of the 
chorion make a distinction between them, as a rule, comparatively sure. 

Symptoms. — The condition is peculiar to married women, although 
minute shreds are observed in single women. The membrane is cast off 
on the second or third day of the flow, as a whole, or at any rate in 
tangible pieces, every month, or every second, third, or fourth month. 
The discharge is accompanied by severe colicky pains which are sometimes 
of a most violent nature. The flow may be excessive or normal in quantity ; 



DISORDERS OF MENSTRUATION 367 

but it frequently presents an intermittence, due probably to the plugging 
of the OS internum by the membrane. The patients are sterile, and this 
state is due to the mucous membrane being so altered pathologically that 
it does not form a suitable nidus for the ovum. Membranous dysmenor- 
rhoea is frequently associated with other uterine disease, such as 
uterine catarrh or displacements ; but these alone do not account for 
its existence. 

The prognosis is uniformly unfavourable, as in most well-marked cases 
it continues during the menstrual life of the patient. 

Treatment. — Any existing complication should, of course, be removed ; 
and thereafter the dysmenorrhoea is best treated by free dilatation of the 
cervical canal, curettage of the uterus, and the application of strong 
escharotics to its interior. Intra-uterine drainage, too, has sometimes 
been followed by fairly satisfactory results. If these means fail, and the 
patient's suffering continue, the alternative of removal of the appendages, 
so as to induce premature menopause, would have to be considered. 

Internally no medicines have a better effect than the continued use 
of arsenic, iodide of potassium, and mercury. 

II. Extra-uterine Dysmenorrhoea. — The extra-uterine variety of 
dysmenorrhoea is that which has its origin in some abnormal condition 
of the uterine appendages. It is commonly called " ovarian," but in 
many cases the cause of the pain lies in the Fallopian tubes, or in the 
pelvic peritoneum in the neighbourhood of the ovary. 

This form of dysmenorrhoea is associated with a very definite set of 
symptoms, and it may occur either in the single or married woman : it 
is found, however, more frequently in married or parous women than in 
the single, for reasons we shall presently see. The ovaries and tubes 
in young women may become the seat of inflammatory changes, as the 
sequela of any of the exanthemata, or as an after result of influenza, or, 
at times, as the consequence of a direct chill. At other times, again, they 
may become thus affected in young women by an inflammatory process 
spreading from neighbouring organs. In married or parous women, 
while these influences may be at work in producing a salpingitis or 
ovaritis, or a combined salpingo-ovaritis, yet in these there are other 
factors more prominently at work ; the first of them is the spreading of 
sepsis into the uterine appendages as the result of abortion or parturition. 

In these cases, if the inflammatory process be at all well marked, 
and more especially if, as is generally the case, it aifects both sides, the 
usual results are acquired dysmenorrhoea and sterility. Now such a 
condition can be quite well recognised clinically, though it may present 
different features in various cases. For example, one or other ovary may 
be simply enlarged, tender, and prolapsed low down into the pouch of 
Douglas ; of the two ovaries the left suffers most. Again, the tube may 
be enlarged and thickened, or may be the seat of one of the grosser 
lesions, such as hydro-, pyo-, or hsematosalpinx ; or the appendages on 
one or both sides may be matted together by perimetric effusion and 
deposit. Further^ there is a cause, but too frequent, both in single 



3^S SYS TEA/ OF GYNECOLOGY 

and married women, of inflammatory disease of the uterine appendages ; 
namely, the infection from gonorrhoea. Yet another source of infection 
is, unfortunately, well enough known ; a salpingo-ovaritis may very easily 
be set up as a result of ill-managed operative interference on the uterus 
itself, by the improper or injudicious use of instruments, and by the 
disregard of antiseptic precautions. 

It must be obvious that no such condition of salpingo-ovaritis can 
be present to any extent without implication of the uterus in the 
inflammatory change; hence it comes that under these conditions a 
mixed form of dysmenorrhoea is met with : the symptoms are sufiiciently 
definite, however, to indicate the tubal and ovarian origin of the pain. 
It is no part of my present duty to describe the symptoms in general to 
which tubo-ovarian inflammation gives rise, among which are constant 
pelvic pain, menorrhagia, pain during defsecation, dyspareunia, and, 
especially dysmenorrhoea. Xow this dysmenorrhoea manifests itself in a 
characteristic way. It is essentially premenstrual,, that is to say, the 
constant pelvic uneasiness of which the patient complains passes into 
definite suffering and pain from three to six days before the external 
manifestation of menstruation. If the uterus be but slightly implicated 
the patient sometimes gets relief on the onset of the haemorrhage ; but, 
on the other hand, if the endometritis be marked, or the salpingo-ovaritis 
of a high degree, the pain will probably continue all through the 
period. This pain is mainly confined to the region of one or other ovary, 
and is often so severe as to keep the patient in a state of unrest for 
days before menstruation sets in. 

The reason of this premenstrual pain is that the tubes and ovaries, 
already in a chronically inflamed state, become gradually more and more 
congested as the da}^ of menstruation approaches ; thus when the flow is 
established in many cases, and the congestion reduced, a corresponding 
relief is obtained ; and the patient, although never absolutely free from 
pain, remains comparatively well for ten days or a fortnight after her 
period. 

The prognosis is essentially bad. Perhaps, next to membranous 
dysmenorrhoea, this variety is the most difiicult to cure. In the form 
affecting young girls the results are decidedly more satisfactory than in 
those women in whom the disease is directly the result of abortion, 
parturition, or gonorrhoea. Further, one main element in the prognosis 
is the ability of the patient to obtain the advantages of long rest and 
prolonged treatment. Yet in any case, so far as the cure of the 
dysmenorrhoea is concerned, the prognosis must always be very guarded. 

In this, as in all other varieties of dysmenorrhoea, there are two 
methods of treatment — the medical and the surgical With regard to the 
medical treatment ; as the constant cycle of changes, through which 
the uterus and its appendages are month by month passing, is one of 
the most important factors in the delay of cure, it is clear that the 
patient must be withdrawn from any conditions which might accentuate 
these changes. Hence the first provision is complete rest — mental, 



DISORDERS OF MENSTRUATION 369 

physical, and sexual. This must be associated with those remedies 
which reduce hyperaemia and discuss deposits. First and foremost comes 
systematic hot douching, accompanied by the introduction of ichthyol, 
either as a pessary or as a dressing, into the vagina. I know of no drug 
which has a more powerful local effect, and I am confident that its per- 
sistent use has saved many an ovary from the surgeon's knife, but its use 
must be persistent. To paint the roof of the vagina with iodine (half- 
and-half tincture and liniment) twice a week, and to place an occasional 
blister over the brim of the pelvis, will facilitate the cure. Internally 
liquor hydrargyri perchloridi, with iodide of potassium and saline 
purgatives, will be found beneficial. 

It is obvious that such treatment will in any case be tedious, and 
more or less so according to the severity of the inflammation : thus it 
must be evident that such treatment is obtainable only by the compar- 
atively well to do ; and even in them, when the condition has become 
chronic, a complete cure is by no means frequently met with. In these 
patients, after the treatment has been carried out at home for some 
months, a course of baths at Woodhall Spa or Ems will be of mucli 
value. For the palliative treatment of the dysmenorrhoea proper most 
of the drugs to which I have already referred will give temporary relief. 
Yet it comes about that under three possible circumstances, surgical 
treatment has in many cases to be taken into consideration : these cir- 
cumstances are — (a) longstanding and intractable dysmenorrhoea ; (ft) 
various mental and nervous phenomena, said to be associated with dys- 
menorrhoea ; and (c) inflammatory or grosser lesions in the uterine 
appendages associated with dysmenorrhoea and other symptoms. 

I think there are few cases, if any, in the first set in which the pro- 
cedure can be recommended, as most kinds of uterine and extra-uterine 
dysmenorrhoea can be palliated without recourse to oophorectomy. It 
is only justifiable when the dysmenorrhoea is associated with the other 
well-marked symptoms to which tubal and ovarian disease gives rise. 
The operation, as a rule, is an easy one, and is undertaken too often 
on insufficient grounds. Further, even after oophorectomy a cure is 
by no means uniformly obtained, because, as I have already said, the 
menopause is not invariably induced; the patient often menstruates 
regularly, and sometimes even with pain : moreover, though menstru- 
ation may cease, periodic monthly pain may recur for a year or two 
at least. In all cases removal of the ovaries should not be adopted 
until all other means of treatment have failed ; and then only as a last 
resource. 

Intermenstrual Pain. — There is a form of dysmenorrhoea, if so it 
may be called, which occurs, not at the time of the external manifesta- 
tion of menstruation, but at mid-term ; to this condition the Germans 
have given the more appropriate name of " Mittelschmerz " ; the French, 
less felicitously, the name of " Dysmenorrhee intermenstruelle." What- 
ever name may be applied to it — and certainly intermenstrual dysmen- 

2b 



370 SYSTEM OF GYNAECOLOGY 

orrhoea is not a suitable one — the condition in which an attack of 
dysmenorrhoea proper is simulated, without, necessarily, any external 
haemorrhage, is well ascertained. It does not at all resemble the pre- 
menstrual pain, or the continued pain associated with inflamed or 
diseased ovaries ; but it is a condition which occurs definitely each 
month, at a definite period, and for a definite number of days. 

So far as I am aware, the condition was first of all described by Sir 
William Priestley many years ago ; it has been also discussed by Fas- 
bender and Sorel. 

The four cases recorded by Priestley had the following as their prom- 
inent features : pain, paroxysmal, in the region of the ovary, occurring 
during the intermenstrual period ; in some cases continuing up to the 
commencement of the flow, in others stopping before it ; the ordinary 
flow is usually scanty, but regular, and with no pain. In two cases a 
tumour was felt, on bimanual examination, in the region of the broad 
ligament, adherent to the uterus, elastic to touch. In the other two 
cases only thickening in the region of the broad ligament was found. 

Sorel records a case presenting symptoms similar to those mentioned 
above, in which the condition had existed for a great number of years ; 
indeed, it had been observed during a period in which 147 menstrual 
epochs had occurred. The chief conclusion arrived at by this author 
was that the occurrence of the intermenstrual pain bore a more defi- 
nite relation to the commencement of the period which followed it than 
to the period which went before ; as fourteen days always elapsed be- 
tween the occurrence of the pain and the commencement of the men- 
strual period. 

One of the most important contributions to the very scanty literature 
of this subject is an article by Heinrich Fasbender, in which he expresses 
his view of the etiology of Mittelschmerz as follows: — Accepting Pflii- 
ger's theory of menstruation, we have in some cases a premature sum- 
mation of nervous stimuli in the ovary, with the occurrence of ovulation, 
caused either by a delicately organised and excitable state of the whole 
nervous system, or of the nerves of the ovary ; the latter state produced 
by a pathological condition of the ovary. This abnormal irritability, 
leading to dehiscence of a follicle some fourteen days before the proper 
menstrual period, produces the congestive condition of the pelvic organs 
found in cases examined at such a time. 

" Mittelschmerz," with a slight flow of blood, is also described by 
Herr Benicke as occurring in a case where there existed a conical cervix 
with pin hole os, anteflexion of the uterus, and retraction of the utero- 
sacral ligament. 

From the above notes along with my own recorded cases (8), the con- 
dition, it seems to me, can be well considered under three different man- 
ifestations : (a) A group of cases in which there is no external discharge 
at all. (5) Those cases where the pain is associated with an escape of 
blood, (c) Those in which, as in two of my cases and some of the others, 
the intermenstrual pain is associated with a clear discharge. 



DISORDERS OF MENSTRUATION 371 

It would be absurd to dogmatise upon the causes of this condition ; or 
to lay down any hard and fast rules as to the pathological conditions 
necessary to its production : but it seems to me that the above classifica- 
tion gives a fair insight into the different states that may lead to the 
production of this somewhat unusual symptom, (a) Of those cases where 
no external manifestation accompanies the occurrence of '• Mittelschmerz," 
the explanation is probably to be found in the fact that ovulation and 
menstruation do not in these cases occur simultaneously ; and that, in 
addition, owing to thickening of the capsule of the ovary or some such 
cause, dehiscence of the follicle is attended with pain. (5) Those 
associated with escape of blood. In all of these it will be observed 
that more or less endometritis, anteflexion, and enlargement of the 
uterus were present ; and, so far as I am able to judge, these were simply 
cases in which a slight intermenstrual flow, due to endometritis, was 
accompanied by well-marked pain during the passage of clots. Such 
a condition is well recognised and common, and scarcely, I think, 
should come under the category of '• Mittelschmerz " at all. Still, 
it adequately enough describes a set of cases to which the Germans 
especially have drawn attention, (c) Lastly, in those cases in which a 
leucorrhoeal discharge occurs with the " Mittelschmerz," and in which, 
just before the usual date of the occurrence of the pain, a swollen and 
fluctuating condition of the tubes was in some cases made out, I think 
there can be no question that the cause of the intermenstrual pain 
was to be found in hydrops Fallopii, reaching its full development at 
mid-term. 

I am well aware that much doubt is now thrown upon the possibility 
of what is called " intermitting hydrosalpinx," or " hydrops tubse pro- 
fluens " — the occasional sudden escape of fluid through a temporarily 
patent uterine end, with disappearance or diminution in size of the 
tubal dilatation. According to some authors, it is much more likely 
that these discharges pass away, not by the cervix, but by a vaginal 
fistula communicating with the cyst. Either explanation is compatible 
with this view of mine. 

In the cases I have recorded (8), in Avhich a removal of the tubes and 
ovaries brought about a cessation of the " Mittelschmerz," it may be urged 
that the pain had been ovarian, and that its cessation was due not to 
the removal of the hydrosalpinx, but to the removal of the ovary. 
Here I would remark that colicky pain in the tubes does occur in such a 
condition, contractions of the sac forcing the fluid through a uterine 
orifice only partially closed; and also that pain may be due to dis- 
charge of uterine contents, the result of reflex contraction of a neces- 
sarily congested uterus. Thus it is more than likely that the pain 
is really tubal. 

J. Halliday Croom. 



372 SYSTEM OF GYNECOLOGY 



REFERENCES 

1. Allbutt, T. Clifford. Med.-Chir. Trans. 1865-6, xlix. 161-164.— 2. Beau, De. 
Amer. Med. Journ. vol. xi. — 3. Benicke. See Fasbender, No. 29. — 4. Bouchart. Gazette 
des Hopitaux, November 1876. —5. Campbell. Northern Journal of Medicine, 1845. 
— 6. Champneys. "On Painful Menstruation," Harveian Lectures, 1890. —7. Cook, 
W. Med.-Chir. Trans. 1813. — 8. Croom, H. Edin. Med. Journ. 1896, vol. i.— 9. 
CzEMPiN. Zeits. f. Geb. nnd Gyn. Bd. xiii. Heft 2.-10. Englemann. Amer. Journ. 
Obstet. vol. viii. 1875-6, p. 30. — 11. Fasbender. Zeits. fur Geburtshiilfe u. Frauen- 
krankheiten, 1876.-12. Fritsch. Die Lageverdnderungen und die Entziindangen der 
Gebdr mutter. Stuttgart, 1885. — 13. Harding, C. Lancet, 1879.-14. Harle, C. E. 
Brit. Med. Journ. June 1880. — 15. Harris, Amer. Journ. of Obstetrics, vol. iii. p. 616. — 
16. Hausmann. Berlin Belt, zur Geb. u. Gyn. 1872, S. 155. — 17. Kammerer. Trans. New 
York Acad, of Medicine, 1866-9, iii. pt. 7, pp. 1-10.-18. Kehrer. Zur Sterilitdtslehy^e 
Beitr. z. kiln. Gebiirtsch. 1879-80, ii. 76-139. — 19. Jackson. "On some Points 
connected with the Treatment of Sterility," Tr. Amer. Gyn. Soc. iii. 347-362, 1879.— 
20. Jones. Amer. Journ. Obstet. 1887, vol. xx. p. 92.-21. Lucas, C. Clin. Soc. 
Trans. 1888. — 22. LusK. Amer. Journ. Obstet. 1891. — 23. Morgagni. De Sedlbus 
et Causis Morborum, 2 vols. Venet. 1762.-24. Pozzi. Tralte de gynecologic clinique 
etoperatoire. — 2b. Priestley, Sir W. Brit. Med. Journ. 1872, ii. p. 431.-26. 
Simpson, Sir J. Med. Times and Gazette, 1859, i. p. 179. — 27. Sims. The Lancet, 1865, 
vol. ii. p. 42.-28. Smart, R. B. Med.-Chir. Trails. 1858.-29. Sorel. Archives 
de Tocologie des Maladies des Femmes, 1887. — 30. Virchow. Gesam. Abhandlungen, 
1855, S. 774. — 31. Williams, Sir J. Obstet. Journ. of Great Bi^itain and Ireland, 
1875, vols. ii. and iii. 1877.-32. Wright. Brit. Med. Journ. 1893. — 33. Wylie. A 
System of Gynaecology by American Authors, 1887. 

J. H. C. 



DISEASES OF THE EXTERNAL GENITAL ORGANS 

Hyperemia. — Active or arterial hyperaemia is usually the first stage of 
inflammation. It occurs in infants from want of cleanliness, and in older 
children and adults from mechanical or chemical irritation; such as 
masturbation, scalds, and strong chemical applications. An important 
cause, from a medico-legal point of view, is the rape of young children, 
which is usually followed by much congestion and swelling, but seldom 
goes on to inflammation. 

Passive congestion or venous hyperaemia results from obstruction 
to the venous circulation in liver, heart, or lungs ; also in pregnancy. 
Prolonged venous congestion may lead to permanent varicosity of the 
veins. Passive congestion may cause oedema of the labia majora, both 
labia becoming swollen, white, shining, and translucent. In inflamma- 
tory oedema the swelling is usually unilateral, and involves the lesser, 
as well as the greater labium. 

Treatment. — The treatment of passive congestion should be directed 
to the cause of it. In pregnancy it may often be relieved by a suitable 
abdominal belt, and by the recumbent posture. Should the skin break 
special care is necessary to prevent septic infection; such cases are 
especially liable to erysipelatous inflammation. 



DISEASES OF THE EXTERNAL GENITAL ORGANS 373 

Inflammattoxs. — The characteristics of inflammation of the vulva 
vary, not only with the irritant which causes it and the condition of the 
affected parts, but also with their anatomical structure; so that in- 
flammatory affections can be divided into those which affect the mucous 
membrane, the skin, and the glandular structures respectively. In 
practice, however, it will be found that all these structures are affected 
simultaneously in varying degree. For clinical purposes we may divide 
vulvitis into the following varieties : i. Traumatic ; ii. Catarrhal ; 
iii. Dermal (dermatitis, eczematous, herpetic, pruriginous) ; iv. Ulcera- 
tive ; V. Septic ; vi. Diphtheritic ; and vii. Erysipelatous. 

i. Traumatic vulvitis resulting from burns, scalds, powerful caustics, 
or injuries, usually heals spontaneously. 

ii. Catarrhal vulvitis may be acute or chronic. It is common at 
all periods of life, and is generally due to some constant source of 
irritation, or to the introduction of septic material from without; by 
want of cleanliness, contact of dirty fingers as in scratching, coitus, 
masturbation, gynaecological manipulations, dirty sponges, soiled linen, 
septic vaginal discharges such as putrid lochia and menstrual flow, and 
those resulting from neglected tampons, sloughing cancer or myoma: 
or by contact with ammoniacal or saccharine urine and faeces in cases of 
vesico-vaginal and recto-vaginal fistula. In infants the causes are want 
of cleanliness and constant contact with decomposing urine and faeces ; 
in older children, oxyurides wandering into the vagina from the rectum 
lead to scratching and rubbing ; and the wounds thus caused become 
infected and inflamed. At all ages gonorrhoea is a frequent and im- 
portant cause, and the epidemics of vulvo-vaginitis which occur in 
schools are probably attributable to it. 

Purulent vulvitis is generally gonorrhoeal both in children and 
adults. The importance of gonorrhoea in women was pointed out nearh' 
a quarter of a century ago by Noggerath, but has only recently received 
the attention which it deserves. According to Sanger, 12 per cent of 
all the women who consult a gynaecologist suffer from gonorrhoea, and 
considerably more than one-third of sterile marriages are due to this 
disease. Acquired sterility after the birth of one child Sanger believes 
to be due, as a rule, to gonorrhoea. But there may be purulent 
vulvitis which is not gonorrhoeal ; it is met wdth most frequently in 
poorly nourished lymphatic children, and in obese women. 

Signs and Symptoms. — In acute vulvitis there is sharp local pain, 
increased by movement and micturition; the inflamed structures 
become red and swollen, and there is a mucous, muco-purulent, or puru- 
lent discharge. The glands of Bartholin may be involved, leading to 
abscess. In gonorrhoeal vulvitis the symptoms are especially acute. In 
chronic vulvitis the signs are less pronounced ; there is less swelling 
and redness, often excoriation wdth hypertrophied papillae. The glan- 
dular structures about the vulva sometimes participate in the inflamma- 
tion and form small projections, pustules, or boils ; to these the term 
follicular vulvitis has been applied. The glands of Bartholin may also 



374 SYSTEM OF GYNECOLOGY 

be implicated; in which case they are indurated, and exude a little 
milky or greenish pus. Sir Wm. Priestley described a form of vulvitis 
under the name of chronic papillary inflammation of the vulva ; and 
Matthews Duncan a somewhat similar condition, of a very obstinate 
nature, which he considered to be closely allied to lupus. Trachoma 
pudendorum is a name applied by Tarnowsky to a condition found in 
prostitutes as a result of gonorrhoea ; it is characterised by grayish or 
yellowish nodules about the size of a pin's head. 

Diagnosis. — The signs and symptoms are usually clear enough to 
render the diagnosis of vulvitis easy ; but it is often difficult to distin- 
guish one variety from the other. It is especially important, but often 
impossible to determine whether the inflammation present be of a 
gonorrhoeal nature or not. The history of the case is generally want- 
ing or misleading ; but the following features may be looked upon as 
important : — a purulent discharge in the absence of ulceration, erosion, 
or malignant disease associated with inflammation of the urethra and 
glands of Bartholin ; a well-defined reddish margin around the urethral 
orifice, and two bright red spots marking the orifices of the ducts of 
Bartholin's glands (macula gonorrhoica, considered by Sanger as espe- 
cially important) ; warty condylomata complicated with granular 
vaginitis ; salpingo-periraetritis ; sudden development of inflammatory 
disease of the genital organs in a newly married woman, which injures 
her health to a degree out of all proportion to the local condition ; 
habitual abortion ; sterility acquired after the birth of one child ; oph- 
thalmia neonatorum, and especially the detection of the gonococcus. 

Prognosis. — In simple vulvitis, provided the cause can be removed, 
the prognosis is good. Gonorrhoea in women is always a serious dis- 
ease, much more so than in men ; but Yeit believes that the inflamma- 
tion resulting from a single inoculation will always heal spontaneously, 
an opinion he has founded upon clinical observations and experiment. 
He has never met with a case of inflammation of the uterine append- 
ages resulting from a single infection; but repeated inoculations render 
the prognosis a much more serious matter. In general terms it may be 
said that so long as the disease has not advanced above the os internum 
the prognosis is relatively good, but once the tubes and peritoneum 
become inflamed a cure is very improbable. Even when the disease is 
limited to the vulva and vagina, especially if it involve the glands of 
Bartholin, it may run a chronic course; it often remains latent for 
years, and suddenly recurs without fresh infection. An ingenious 
theory to account for this phenomenon has been suggested by Luther 
of Magdeburg. It is well known that the disease usually spreads by 
the gonococci invading and destroying the cells, and the microbes thus 
set free invade other cells. According to Luther's theory, the gonococci 
in the course of time become attenuated, and failing to destroy the cells, 
remain latent in them ; but should a tissue thus invaded become subject 
to traumatic or other injury, the microbes again become virulent and, 
invading other cells, rekindle the original disease. He thinks variation 
in virulence would be a better term than latency. 



DISEASES OF THE EXTERATAL GENITAL ORGANS 375 

Treatment. — The prophylaxis of vulvitis consists in scrupulous 
cleanliness. In schools and institutions it is of great importance that 
each person should have her own basin and towel. Sponges should 
as far as possible be avoided, and certainly they should not be used in 
common. A man suffering from gonorrhoea should be cautioned as to 
the dangers likely to follow a marriage contracted before the disease 
is cured. 

In acute vulvitis the patient should be confined to bed; her diet 
should be of a light, unstimulating character; her bowels should be re- 
lieved by a mild aperient, and she should sit from half to one hour in a 
warm hip bath to which has been added carbonate of soda, permanganate 
of potash or bran; after this a compress wet with liquor plumbi 
subacetatis dilutus (Goulard's lotion), solution of boric acid (I to 2 per 
cent), or salicylic acid (1 in 6000) should be applied and frequently 
renewed. The compress may be either cold or hot as the patient may 
prefer. A similar line of treatment is applicable in some chronic cases, 
but astringent and antiseptic applications will also be required. Solutions 
containing acetate of lead and opium, tannin, carbolic acid (1 in 40), 
sulphate of copper (1 per cent), corrosive sublimate (1 in 3000), 
answer this purpose. In chronic cases, and particularly in the intertrigo 
of fat women, dusting powders will be found of advantage, as for example : 
Acidi borici, Zinci oxidi, aa 3ij. ; Pulv. amyli, 3iv. ; Pulv. rad. iridis 
florentinse, ^j. 

Ointments are less popular now than they were formerly ; still they 
are indispensable in some cases, especially where the surface has to be 
protected from irritating discharges, as in cancer, fistula, and the like. 
A very valuable ointment in such cases is the oxide of zinc ointment of 
the Pharmacopoeia to which 5 per cent of carbolic acid has been added ; 
or, if there be much local irritation, thymol (2 per cent), or cocaine 
(10 per cent). 

In follicular vulvitis the pustules should be opened, and the parts 
fomented with an antiseptic compress. 

In acute inflammation of Bartholin's glands a warm sublimate compress 
should be constantly applied ; and as soon as the abscess shows any tendency 
to point, it should be freely opened, well washed out with an antiseptic 
solution (lysol or creolin), and the cavity packed with moist iodoform 
gauze. In chronic cases a similar course may be followed ; but total 
extirpation of the gland is the most satisfactory means of cure. In 
gonorrhoeal vulvitis nitrate of silver has a great reputation ; but it is 
probably inferior to some antiseptics already mentioned, and according to 
Schaeffer it is decomposed and rendered useless by albumin and chloride 
of sodium ; he proposes as a substitute for it argentamin (diamine- 
silver-phosphate). In the hope of aborting the disease very strong 
caustic solutions have been recommended by some authorities, but this 
hope is illusory owing to the anatomical conditions of the parts and the 
biological peculiarities of the gonococci. A milder and more prolonged 
course of treatment is more satisfactory ; and it must not be forgotten 



376 SYSTEM OF GYNECOLOGY 

that vulvitis is frequently associated with vaginitis, the treatment of 
which should not be overlooked. After bathing or douching, the labia 
should be kept apart by a tampon soaked in iodine and glycerine. In 
very chronic cases benefit has resulted from the use of chloride of zinc, 
ichthyol, and galvanism. 

iii. Dermal Vulvitis. — Simple dermatitis or intertrigo is generally 
met with in fat women, and begins in the groove between the labia 
majora and the thighs. The sweat and sebaceous matter collected in 
this groove, submitted to heat and moisture, decompose, become exceed- 
ingly irritating, and cause inflammation or scalding. 

The inflamed parts should be thoroughly cleansed with warm water 
and some non-irritating soap, or with a soda solution, and then powdered 
with boric acid or iodoform. Or the following lotion may be dabbed 
on: Calaminae prep. 5ss., Zinci oxidi, 3 ij., Glycerini, 3j., Aq. rosae, ad 
5viij. 

EczematoxLS Vulvitis. — Eczema may be acute or chronic, but the latter 
is more common. In acute eczema the patient experiences a burning 
sensation in the labia majora ; this is followed by redness, swelling, and 
the eruption of little vesicles about as large as a pin's head. These are 
often overlooked, and are best seen by a side light. When they burst 
they leave a moist, excoriated surface which rapidly becomes covered with 
crusts. The eruption is attended with a certain amount of fever and 
gastric disturbance. 

The chronic form generally appears as eczema rubrum ; it is seldom 
limited to the labia majora, but rapidly involves the neighbouring skin 
and the mucous membrane of the vagina. It frequently occurs in gouty 
and lymphatic patients, and in association with diabetes. The prognosis 
is usually good, but in some cases the disease is exceedingly chronic. 

In the acute stage cold or warm compresses and subacetate of 
lead lotion are generally all that is needed. Where crusts have formed 
oily applications are necessary, and are generally used in the form of 
ointments. 

When the discharge is profuse and watery the surface should be 
powdered. In more chronic cases Hebra's unguentum diachylum, white 
precipitate ointment, or — I^ Acidi borici 3j., Plumbi acet. gr. x., 
Bismuthi subnitr. 3 ij., Vaselini ad 5 j- ; M. ft. ; Ung. Or again — Pulv. 
amyli, Bismuthi carb. aa 3 j., Cremoris alb. ad 5 j.; M. ft.; Ung. In very 
chronic cases sapoviridis and tarry preparations may be used; the last- 
mentioned, however, with caution. 

Herpes vulvce is characterised by the appearance of little vesicles in 
groups. It occurs most frequently in fat women at the commencement 
of menstruation; pregnancy also disposes to it. The eruption is 
generally preceded by a burning sensation, the vesicles disappearing in 
from seven to eight days. These two affections are very liable to be con- 
founded with one another: eczema, however, has a tendency to spread 
at the edges ; herpes appears in successive crops. In eczema, too, the 
skin is more or less involved and swollen ; this is not the case in herpes. 



DISEASES OF THE EXTERNAL GENITAL ORGANS ^-j-j 

Great care must be taken, however, not to confound either with syphilitic 
eruptions. 

Prurigo. — This affection, which causes very distressing itching, is 
characterised by the appearance of a papular eruption. The little 
papules are of the same colour as the skin, and, according to Klebs, are 
due to dilatation of the lymphatics in the hypertrophied papillae, causing 
irritation of the terminal filaments of the nerves of the skin. 

The diagnosis is more easily made by the touch than by sight, — a 
rough, goose-skin sensation is conveyed to the examining finger. The 
disease, which is of a very obstinate and intractable nature, is happily 
rare in these countries. 

The following formulae are useful : — ^ Menthol, 3 ij., 01. olivae 3 iv., 
Chlorof. 3j., Lanolini 3ij-; M. ft.; Ung. A cone of ol. theobromse 
impregnated with cocaine, 2 per cent (Porritt). ^ Ac. salicyl. 3 ss., 
Creasoti ^^ xl., Glycerini amyli 5iij., Lanolini, 3j. ; M. ft.; Ung. 

iv. Ulcerative vulvitis, or aphthous vulvitis, occurs in young chil- 
dren from two to five years of age, generally after the exanthemata. 
Little circumscribed spots appear upon the mucous membrane, some- 
times ulcerate, and occasionally become gangrenous. This affection 
has been confounded with noma pudendi ; but in this latter disease 
gangrene is an essential characteristic, not an accidental sequela. The 
child's general health should be attended to, and the spots dusted with 
some mild antiseptic powder. 

V. Septic vulvitis is most frequently met with in child-bed in the 
form of a puerperal ulcer; the symptoms which accompany this ulcer 
are fever and smarting on passing water. One labium is usually oedema- 
tous, and when examined upon the inner surface, a fissure or ulcer can be 
discovered having a white base, a red and inflamed margin, and a thin, 
irritating discharge which excoriates the surface of the skin over which 
it flows. Formerly these ulcers were treated very actively, and 
cauterised with strong acids or the actual cautery ; but such violent 
measures are unnecessary : healing usually goes on rapidly when the 
affected part is kept clean and powdered with iodoform. If the poison 
be of a more virulent nature gangrene may extend more widely, and 
leave deep ulcers which, if the patient recover, may lead to stenosis of 
the vulva. 

Noma pudendi is a name applied to gangrene of the vulva occurring 
in young children, especially after the exanthemata, and resembling 
noma of the face which occurs under similar circumstances. This disease 
is due to septic inflammation. It commences with burning local pain 
and fever ; the tissues swell, becoming dusky red, brown, gray, or black ; 
bullae form upon the surface and burst, discharging a thin, ichorous 
serum, and a dark slough is exposed. The disease is generally fatal ; 
but should the patient recover, there will be marked deformity from 
cicatricial contraction. 

The treatment must be general as well as local. Alcohol should 
be given in large quantities, together with easily assimilable nourish- 



378 SYSTEM OF GYNECOLOGY 

ment. Locally the diseased tissues are to be destroyed with the actual 
cautery or fuming nitric acid ; the former is preferable. Some prefer 
excision with careful disinfection of the raw surfaces, the wound being 
closed by suture. 

vi. Diphtheritic and dysenteric vulvitis are complications of the two 
diseases respectively concerned. 

vii. Erysipelas vulvae occurs in young and neglected children. In 
adults it assumes a more chronic form, and has a tendency to recur at 
each menstrual period, disappearing in the intervals. There is redness of 
the skin attended by a burning sensation, pain in the parts, and fever. 
The disease often remains latent during the intervals between the attacks, 
and its recurrence is due to an alteration in the nutrition of the parts at 
the menstrual periods. 

The treatment consists in dusting with powders containing boric or 
salicylic acid, painting with nitrate of silver, the application of com- 
presses of carbolic acid or corrosive sublimate. Hypodermic injection 
of a two per cent solution of carbolic acid, first recommended by Huter, 
has been used with benefit. Benefit has also been derived from rubbing 
turpentine into the skin. 

viii. Pruritus vulvae is the term applied to a chronic and very distressing 
condition which results from a variety of causes. It is doubtful whether 
the affection is ever the result of a pure neurosis, though it is often 
impossible to determine its exact pathological nature. Diabetes is fre- 
quently a cause of pruritis, and it is sometimes due to vegetable parasites, 
such as the leptothrix vaginalis or the oidium albicans. In some cases of 
chronic vulvitis pathological changes occur in the papillae of the skin ; 
especially in the fossa navicularis, on the hymen, and in the neighbour- 
hood of the urethral orifice. The altered condition of the papillae per- 
sists and is a constant source of irritation. 

There are cases, however, in which no pathological cause is discover- 
able, and which, in the present state of our knowledge, must be regarded 
as primary neuroses. This primary pruritis is most frequently found in 
women about the menopause ; very rarely in young women. The chief 
symptoms are itching and burning in and about the labia, especially in 
the clitoris and its immediate neighbourhood ; but sometimes it spreads 
over the mons veneris, thighs, and anal region. The itchiness is seldom 
constant, but mostly occurs in paroxysms. It is aggravated by warmth 
or motion, and is most marked at night. It attains its greatest intensity 
during sexual intercourse. So intolerable does this itchiness become at 
times that women affected with it can hardly refrain from scratching even 
in public, and occasionally their condition becomes such a miserable one 
that in order to escape from it some have committed suicide. 

The first and most important step in treatment is to try to discover 
the cause. But even where no cause is discoverable local treatment 
may give relief. Bathing with carbolic lotion, corrosive sublimate 
(__!__). boric acid lotion, or lotion of subacetate of lead, has been 
found useful. Painting with a strong solution of carbolic acid, or 



DISEASES OF THE EXTERNAL GENITAL ORGANS 379 

nitrate of silver, or with tincture of iodine ; or powdering the parts with 
iodoform and tannic acid, have been known to give relief. Scanzoni 
recommended paintingwithchloroformliniment — two parts of chloroform 
to sixty of oleum amygdalae. Equal parts of powdered alum and sugar 
mixed and dusted over the parts is another method of treatment. Baths 
do good. All rubbing and scratching should, as far as possible, be 
avoided. Eelief from the itching may be given by the application of an 
ointment of cocaine. Internally bromide of potassium, and occasionally 
sulphonal and morphia, have been of service. In some cases arsenic has 
done good. In a few cases, where the itchiness was limited to portions 
of the mucous membrane, benefit has follov/ed extirpation. Fehling 
removed both labia majora and the clitoris in an obstinate case of pruritis 
with permanent benefit. A weak galvanic current deserves a trial, the 
anode being placed on the vulvae, and the kathode applied to the various 
affected parts ; good results from this method of treatment have been 
recorded. The general health should be attended to. 

Venereal Diseases. — Soft chancre generally appears shortly after 
infection, usually within twenty-four hours. It is a small vesicle or 
pustule, often overlooked, which leaves a rapidly spreading ulcer with 
a yellowish base, bright red, sharply defined, or undermined edge, and 
a thick purulent discharge. Soft chancre may be single, but it is 
generally multiple. With appropriate treatment it heals in a few days ; 
though in tuberculous and alcoholic patients it has a tendency to slough 
or to assume a phagedaenic form. The microscope reveals enlarged 
vessels and hypertrophied papillae in the neighbourhood of the ulcer, 
whilst those on the surface are undergoing a process of necrosis. These 
chancres may occur in any part of the vulva. One inguinal gland 
is usually inflamed and generally suppurates. 

Syphilis manifests itself in a hard chancre and the eruptions of 
secondary and tertiary syphilis. The hard chancre usually appears after 
a period of incubation of about one month from the time of infection as 
a little indolent red spot, the base of which becomes indurated, feeling 
like cartilage. It rarely assumes a papular form, but more frequently 
that of an ulcer. As a rule the surface of the chancre is on a level with 
that of the neighbouring tissue. It is usually single, but occasionally 
multiple. 

Secondary syphilis occurs as superficial erosions, from the size of 
a millet seed to that of a sixpence {plaques muqueuses), and papular 
syphilides. Tertiary syphilis occurs in the form of gummata. These 
tumours appear at first as nodules which soften and ulcerate. 

For the constitutional treatment of syphilis I must refer the reader 
to works on that subject. Locally these affections may be dusted with 
antiseptic powder, or cauterised with nitrate of silver. 

TuMOUKS OF THE VuLVA. — Inguinal hernia, though less common in 
Avomen than femoral, is not very rare. The bowel may descend into the 



SSo 



SYSTEM OF GYNECOLOGY 



greater labium through the canal of Nuck, when it is called hernia labii 
majoris anterioris, in contradistinction to the second form, which descends 
through thepel vie diaphragm andis termed hernia labii majorisposterioris. 




Fig. 117. — Descent of perineal hernia in front of the broad ligament. 



This latter form is exceedingly rare. It may occur in two ways : — 
Firstly, the hernia may descend in front of the ligamentum latum, dis- 
tendingthe vesico-uterinefoldof peritoneum, andpassing down between the 
bladder and uterus along the vagina into the labium (vagino-labial hernia) ; 
or it may descend behind the ligamentum latum between the rectum and 



DISEASES OF THE EXTERNAL GENITAL ORGANS 381 

vagina either into the labium or into the perineum. The hernia may 
contain the uterus and ovaries as well as intestine and omentum. The 
diagnosis is of great importance, posterior labial hernia being especiall}^ 
liable to be mistaken for cysts of Bartholin's glands. The annexed 
photograph, taken from a patient in the Eotunda Hospital, shows a 
large perineal hernia which had descended in front of the broad ligament. 
About half the contents could be reduced into the abdominal cavity, and 
as they again descended into the sac could be felt through the vaginal 
wall. 

Varicocele is a very common result of pregnancy, tumours, and con- 
stipation. This condition seldom gives rise to much disturbance. The 
patient complains of a feeling of weight and distension often attended by 
itching. The chief danger is rupture of a vein, cases of fatal result 
having been recorded as following this accident. 

Compression of the veins, so useful in varicose condition of the lower 
extremities, is difficult to carry out in this situation. A T bandage and 
compress is so inconvenient that it can only be adopted in the worst cases. 
We are obliged to restrict our measures to rest in bed and the use of 
astringent washes. In case of rupture haemorrhage should be controlled 
at once by the application of a compress and, as soon as the necessary 
preparations can be carried out, by ligature. 

Haematoma, or thrombus vulvae, generally occurs during labour 
from the rupture of varicose veins, blows, or wounds. An elastic 
globular tumour of a deep purple colour forms in the labium which 
is neither hot nor tender. This is accompanied by a feeling of tension 
and a desire to urinate. The tumour may burst, or there may be 
internal haemorrhage without rupture of the tumour. In either case 
the patient frequently bleeds to death. Should she survive, putrefaction 
of the effused blood may occur with symptoms of sapraemic infection or 
acute pyaemia. 

In small effusions an ice-bag may be applied; but in more severe 
cases it is better to lay open the cyst by a free incision and control 
the haemorrhage by suture, or by firmly packing the cavity with gauze. 
Should symptoms of putrefaction or suppuration occur the cyst should be 
thoroughly evacuated, disinfected, and treated in a similar manner. 

Warty condylomata are generally the result of venereal infection, 
but may occur independently of this cause, especially in infants and 
pregnant women. They usually commence in the folds between the 
labia majora and minora. They sometimes occur singly, but are often 
agglomerated so as to form very large tumours. There is hypertrophy 
of the papillary layer of the skin. They may spread over the hymen,, 
the perineum, and around the urethra and anus. The symptoms are 
not very pronounced, and are chiefly due to the irritating discharge. 
Large tumours cause a feeling of weight ; but as a rule patients only 
complain of burning and smarting. These growths may be dusted with 
an astringent antiseptic powder, but the most satisfactory method is 
their total removal with scissors or knife. 



382 SYSTEM OF GYNECOLOGY 

Elephantiasis is a disease seldom met with in these countries. It is 
characterised by a local hyperplasia of the skin, and by an increase of 
subcutaneous connective tissue. The surface is sometimes smooth and 
shining — elephantiasis glabra ; sometimes warty — elephantiasis verru- 
cosa ; sometimes covered with projections — elephantiasis papillomatosa : 
sometimes the swelling feels hard, at other times soft. The lymphatics 
are enlarged, and there is a small-celled infiltration around the blood- 
vessels, especially round the veins, with an increase of connective tissue. 
It is not certain whether the lymphatic dilatation is a primary or secondary 
affection. 

Etiology, — Very little is known of the causation of this disease, but 
the fact that it is endemic in certain countries points to infection. It 
usually begins between the ages of 15 and 40, but has been known to 
begin in infancy. Various causes have been assigned, such as syphilis, 
soft chancre, scrofula, masturbation, and various inflammations, especially 
erysipelas. None of them, however, occurs with sufficient constancy to be 
accepted as an undoubted cause. 

Symptoms. — In hot climates the disease often commences as an acute 
affection, but not so with us. The hypertrophy is attended by itching, 
smarting, and some discharge ; but the patients chiefly complain of a 
feeling of weight due to the size of the tumour, which also causes diffi- 
culty in walking, cohabitation, micturition, and defsecation. 

Diagnosis. — This disease is liable to be confounded with other hyper- 
trophic skin diseases associated with ulceration, especially with lupus and 
cancer. In both these affections the ulceration is more extensive, and in 
the latter case it runs a much more rapid course. 

Treatment. — Elephantiasis is essentially a chronic disease, and, ex- 
cepting from some complication, does not endanger life. It does not, 
however, yield to treatment; and strapping, which Hebra found so 
beneficial when the disease involved the lower extremities, can seldom be 
employed where it attacks the vulva. The only treatment likely to 
give relief is total removal. This is best accomplished by the procedure 
introduced by Schroeder, namely, to begin at the posterior limit of the 
disease and remove it bit by bit, closing each portion of the bleeding 
wound by suture. 

Lupus. — If we limit the name lupus to disease undoubtedly tubercular, 
then lupus of the vulva is almost wholly unknown. In one case only were 
tubercle bacilli demonstrated, namely, by Viatte in 1891. In another case 
giant cells and caseous degeneration were observed by Birch-Hirschfeld ; 
but in the great majority of cases commonly called lupus no tubercular 
disease is demonstrable. Such cases are characterised by infiltration of 
the mucous membrane, which soon ulcerates, and the ulceration spreads 
superficially, often healing in one place while it extends in another. The 
disease usually commences in the labia minora, spreading gradually to the 
clitoris and vagina. The ulcers are often excavated with jagged edges. 
The base is sometimes red, sometimes yellowish, and covered with small 
nodules or polypoid outgrowths. The vesico-vaginal and recto-vaginal 



DISEASES OF THE EXTERNAL GENITAL ORGANS 383 

walls are often tlie seat of infiltration leading to ulceration, which 
frequently causes fistula. 

Symptoms. — At first the symptoms are not well marked. When 
ulceration occurs there are irregular hsemorrhages and leucorrhoea, but 
rarely pain. The progress is slow ulceration, healing in one direction, 
whilst it extends in another. 

Diagnosis. — Syphilis is distinguished by the general symptoms 
and history, and, in doubtful cases, by a course of special treatment. 
Cancer is distinguished by its more rapid growth, its general appear- 
ance, glandular implications, and deeper ulceration. In elephantiasis 
hypertrophy rather than ulceration is the chief feature, and it most 
frequently involves the labia majora; whereas lupus is characterised 
more by ulceration than hypertrophy, and the lesser labium is pri- 
marily affected. 

Treatment. — The only successful treatment consists in the removal 
of the disease either by the knife, by curettage, or by the actual or poten- 
tial cautery ; but where the disease involves the vesico-vaginal or recto- 
vaginal septum the greatest possible care must be taken not to open 
either the bladder or the rectum, as the diseased structures will not 
readily unite ; indeed, it would probably be found impossible to repair 
such an injury. 

Malignant disease occurs in the form of epithelioma, medullary 
cancer, scirrhus, and sarcoma. Primary cancer of the vulva is com- 
paratively rare; but of the forms mentioned epithelioma is much 
the most frequent. It begins generally in the larger labium, or in the 
cleft between the labia majora and minora, where the cutaneous and 
mucous structures become continuous. It first appears in the form of 
little nodules in the skin which become warty, shed their epithelium, 
and discharge a watery fluid tinged with blood. An ulcer forms which 
spreads superficially at first, but later extends more deeply, and involves 
the neighbouring structures. The inguinal glands in the early stage of 
the disease become sympathetically enlarged ; subsequently the enlarge- 
ment is due to infiltration. At first the disease is confined to one side, 
but the opposite labium becomes involved in many cases, probably 
through inoculation. 

Symptoms. — The earliest symptom is pruritus, more particularly 
when the clitoris is involved. The ulceration and discharge cause dis- 
comfort; but pain is seldom complained of until the disease is far 
advanced. Haemorrhage is a late symptom and one that rarely proves 
fatal. Death occurs in the majority of cases from marasmus attributa- 
ble to chronic septic infection, and metastasis. 

Prognosis. — The prognosis is bad; however, a few permanent cures 
after operation have been recorded. 

Treatment. — Total removal of the disease is the only method of 
treatment which holds out a prospect of cure. Birschoff has recorded 
good results from the galvano-cautery. Most operators prefer the knife ; 
but if cancer be inoculable, then the destruction of the disease with the 



384 SYSTEM OF GYNECOLOGY 

actual cautery affords a better prospect of radical cure than any cutting 
operation. 

In cases where operation is undesirable, the putrid and irritating 
discharge can be controlled for a time by scraping and the cautery. 
Where the disease is too far advanced for this treatment, the ulcers 
may be sprinkled with equal parts of iodoform and charcoal, and 
dressed with absorbent gauze. 

Fibroids occur most frequently in the larger labia, but are some- 
times found upon the perineum and the nymphse. These tumours are 
encapsuled, and consist of muscular and connective tissue ; sometimes 
they attain large dimensions and become pedunculated. Although 
these tumours are not in themselves dangerous to life, yet sometimes 
the inconvenience due to their weight and position render their removal 
advisable. 

Lipoma. — The favourite site of these tumours is the neighbourhood 
of the mons veneris and larger labia. In appearance they resemble 
elephantiasis, but on extirpation they are found to consist of fatty tissue. 

Enchondroma. — Enchondroma of the clitoris. One case has been 
recorded by Schneevogt. Ossification of the clitoris mentioned by 
Beidel is probably of this nature. 

Neuroma. — Simpson has described one case and Kennedy another. 

Angioma. — This variety of tumour is exceedingly rare. 

Cysts. — Apart from the cysts of Bartholin's glands, other cysts 
occur in the labia and neighbouring region; however, they are com- 
paratively rare, and are due to obstructed glands, haemorrhage, or 
dilated lymphatics. 

Kraurosis Vulvas. — Our knowledge of this affection is due to the 
late Professor Breisky of Prague, Dr. Martin of Berlin, and his assist- 
ant Dr. Orthman. It is characterised by a peculiar atrophic shrinking 
of the integuments of the external genitals and perineum, resulting in 
obliteration of the normal folds. 

The tissues affected become dry, shrink, lose their normal elasticity, 
and become so brittle that the most careful examination may cause 
deep fissures. The surface assumes a whitish macerated shining 
appearance. 

The microscopic examination reveals atrophy of the corium, espe- 
cially of its upper layer. The papillae are ill-developed, and the rete layer 
so thin that the epidermis lies directlj^ upon the papillae. The seba- 
ceous glands are absent, and only a few remnants of sweat glands 
remain. There is found a small celled infiltration of the papillae in 
the deeper layer of the corium. At the margin of the disease Orthman 
found the tissues hypertrophied, a small celled infiltration of the corium, 
and a flattening out of the papillae. 

Symptoms. — In some cases symptoms are slight or absent ; but gener- 
ally there is a most unpleasant itchiug and burning sensation, especially 
during micturition, and occasionally an irritating discharge. Owing to 
the narrowing of the vulva, and the tenderness, rigidity, and brittleness 



DISEASES OF THE EXTERNAL GENITAL ORGANS 385 

of the tissues, the disease may render coitus excessively painful or 
impossible. The cause of this condition is unknown. 

Treatment. — This disease does not yield to any remedy, but removal 
of the tissues involved has been followed by complete relief without any 
subsequent recurrence. 

Vaginitis, Colpitis, or Elytritis. — The Normal Vaginal Discharge. 

— In its healthy state the vagina contains a discharge, to the character 
and nature of which Doderlein has given special attention. He restricts 
the term normal to a discharge having the following main features : — 
It is a whitish gray material, of the consistency of clotted milk, of 
intensely acid reaction, and containing an almost pure culture of the 
vaginal bacillus ; of other micro-organisms, the odium albicans and the 
yeast fungus can occasionally be detected. Saprophytes are rapidly 
destroyed in this material, probably owing to its acidity. It never 
yields pathological germs by culture ; and its injection into animals is 
followed by equally negative results. In describing this discharge I 
have purposely avoided the term secretion, for, in connection with a 
membrane practically destitute of glands, it seems to me incorrect to 
adopt that term; it is more proper to consider it as an exudation 
from the general vaginal surface. Be this as it may, its exact source 
remains a question of uncertainty. It has been asserted by some authors 
that it comes from the cervix and from the vulvo-vaginal glands ; but 
the absence of mucus from its component elements negatives such a 
hypothesis. 

The pathological discharge, which is an important symptom of 
vaginitis, but is found independently of that affection, is of a yellow 
or greenish yellow colour, of creamy consistency, sometimes frothy, or 
mixed with viscid mucus, feebly acid or even alkaline in reaction, and 
contains various micro-organisms. The essential distinction between the 
normal and the abnormal discharge is, that whereas saprophytes perish 
rapidly in the former material, the latter constitutes an environment 
peculiarly favourable to their growth. It is, therefore, evident that the 
vaginal discharge must be modified before it can become a soil suitable 
to the life and development of saprophytes and other germs. Such a 
modification is effected by the copious alkaline efflux which descends 
from the uterine cavity during menstruation, child-bed, uterine catarrh, 
and cancer ; or from the cervix when that part is in a state of catarrhal 
inflammation. In the diseases last mentioned the germs for the most 
part reach the seat of pathological change through the vagina; but so 
long as the vaginal discharge is normal that structure maintains its in- 
tegrity. Sexual intercourse often conveys noxious matter into the 
vagina — saprophytes, tubercle bacilli, and other germs ; but, contrary 
to what might have been expected, even in gonorrhoea the vagina is 
seldom primarily affected, but becomes so secondarily from the uterus, 
the vulva, or the urethra. No doubt the anatomical structure of the 
membrane helps to preserve it from invasion; which is much more 

2c 



386 SYSTEM OF GYNECOLOGY 

likely to occur when it is altered by constant contact with copious 
irritating discharges such as flow from the uterus in cancer, sloughing 
myoma, and septic puerperal affections, or by irritating alkaline urine 
and fseces in urinary and faecal fistulse. Similarly foul, ill-fitting, or 
neglected pessaries — especially those made of soft rubber or wood — 
neglected tampons and other foreign substances, the actual or potential 
cautery, vaginal douches when used too hot or with foul vaginal tubes, 
gynaecological manipulation with septic hands and instruments, not only 
remove or destroy the normal vaginal discharge, but macerate and irri- 
tate the mucous covering, and lead to exfoliation of the epithelium and 
other anatomical changes which render the part liable to the invasion of 
disease. Certain constitutional diseases, such as tuberculosis, dispose to 
leucorrhoea ; and the exanthemata, as well as erysipelas, diphtheria, and 
dysentery, must be included amongst the causes of vaginitis. 

Simple Catarrh. — In this disease, when acute, the mucous membrane 
is uniformly swollen, and of a bright red colour ; the rugae are exagger- 
ated ; there is a small celled infiltration of the epithelial structures, and 
a shedding of epithelial cells. The discharge is feebly acid or alkaline. 
It contains leucocytes and other micro-organisms, besides desquamated 
epithelium. When chronic it appears to have a selective affinity for the 
anterior vaginal wall, and the signs and symptoms are less marked. 
Granular vaginitis is often gonorrhoeal, and is most marked in pregnant 
women. The papillae are hypertrophied, infiltrated with small cells, 
and fused together so as to form the so-called granulations, the epithelial 
covering of which is shed so that they assume a dark red colour. 

Gonorrhoeal Vaginitis. — The mucous membrane is red, hot, and 
swollen; the discharge, which is profuse, is at first creamy, but be- 
comes purulent with the progress of the disease. The papillae are 
evident to the sight and touch. Gonococci are found in the discharge, 
and in the epithelial cells and leucocytes. In the chronic form the 
disease is generally confined to the fornices and vulvo-vaginal glands. 

Vaginitis vetularum vel adhesiva is, as its name implies, peculiar 
to women who have passed the menopause. The membrane is smooth, 
reddish, and atrophied in patches which are denuded of epithelium. 
These denuded surfaces are due to defective nutrition rather than to 
the action of micro-organisms ; and they tend to grow together, forming 
firm adhesions. In some cases the fornices become entirely obliterated 
by their surfaces growing together, or by their adhesion to the cervix ; 
in other cases the adhesion occurs so low in the vagina that the cervix 
can be neither felt nor seen. When recent the adhesions may be broken 
down and the natural shape of the vagina restored; but, as a rule, 
this will be found impossible. This form of vaginitis is so common 
that few women over sixty years of age will be found without some 
adhesions. 

Symptoms of Vaginal Catarrh. — In the acute form the patient com- 
plains of hot and burning feelings, accompanied with a bearing-down 
sensation with increased secretion, at first serous, then mucous, muco- 



DISEASES OF THE EXTERNAL GENITAL ORGANS 387 

purulent, and often purulent. The vulva is generally involved, and 
sometimes tlie urethra, in which case the patient complains of frequent 
and painful micturition. In chronic vaginitis the profuse discharge is 
what the patients chiefly complain of. In adhesive vaginitis there are 
no symptoms except occasionally a thin discharge. 

Physical Signs. — The iinger feels the soft and swollen membrane 
and consequent narrowing of the canal. In the granular form the 
hypertrophied papillae feel like granules upon the surface. When the 
speculum is passed, the membrane is observed to be red and swollen, 
and the foldings exaggerated. In some cases bright red papillae pro- 
trude above the surface, and a fair estimate can be formed of the amount 
and character of the discharge. In the senile form the adhesions can 
be detected by the finger. 

Prognosis. — Vaginitis may be regarded as a curable disease in every 
case in which the cause of it is remediable. The prognosis is doubtful 
in cases of gonorrhoeal vaginitis, because the disease in the cervix, in 
the vulvo-vaginal glands, and in the husband, may not be curable ; and 
it is absolutely bad when the affection is due to persistent irritating dis- 
charges, as in incurable fistula and cancer. 

Pro2)hylaxis. — Amongst prophylactic measures the most important 
are, firstly, to prohibit marriage to men suffering from gonorrhoea for at 
least two years from the time of infection ; and if Veit's observations 
be correct, it is almost as important that a woman who has been infected 
with gonorrhoea should cease to cohabit with her husband until both 
have been cured. The third point is the importance of asepsis in minor 
practice ; the avoidance of routine douching, and care in the use of pes- 
saries, plugs, specula, and other instruments. 

Local Treatment. — In treating a patient who has actually acquired 
vaginitis, the method to be pursued will vary not only with the kind 
of inflammation, but also with the condition in which it may present 
itself — whether acute or chronic, a fresh inflammation or one of long 
standing. The first duty of the practitioner will be to remove the 
cause of the inflammation provided that it can be discovered. He should 
remove pessaries and plugs, cure fistuise, and treat cervical and other 
diseases which may be the causes of the vaginitis. 

In acute vaginitis the vagina may be irrigated with mild antiseptic 
douches, either hot or cold. The most frequently used are corrosive 
sublimate (1 in 2000), carbolic acid (2 per cent), creoline or lysol (1 per 
cent), salicylic acid (i per cent), boric acid (3 per cent) ; should these 
be too irritating, lead lotion or permanganate of potash may be sub- 
stituted. In many cases no antiseptic at all can be tolerated ; in these 
the vagina is irrigated with plain water, gruel, or linseed tea. As acute 
vaginitis is always accompanied by vulvitis, sitz baths, rest in bed, and 
other treatment adapted to this condition must be used at the same time. 

Subacute or chronic vaginitis is best treated by local applications 
applied through a speculum, the patient lying upon her back. A cylin- 
drical speculum does very well ; but a modification of Sims' speculum, 



388 SYSTEM OF GYNECOLOGY 

lined with platinum or made of vulcanite, is better : by means of this 
instrument the perineum is drawn backwards, and the vagina then filled 
with the solution. The best applications for this purpose are crude 
pyroligneous acid of commerce, or solution of sulphate of copper (2 to 
5 per cent). In gonorrhoeal cases nitrate of silver (5 per cent) is 
appropriate. In some cases benefit results from painting the surface 
of the vagina with tincture of iodine, or dusting it with iodoform or 
other antiseptic powders. In very chronic cases astringents will be 
found more useful than antiseptics ; amongst these may be mentioned 
dermatol, tannin, or alum and sugar in equal parts. These are best 
applied in powder. Astringent injections may be employed by the 
patient herself; amongst the most useful of these are douches contain- 
ing alum, sulphate of zinc, borax, and oak bark. In other cases we may 
use pessaries, made of cocoa butter or glycerine and gelatine, contain- 
ing the antiseptic or astringent application desired. This method is 
more popular than it otherwise would be, as the patient herself can 
readily introduce the remedy ; but oily substances are bad vehicles for 
antiseptic remedies. If made with glycerine and gelatine, which is the 
form I prefer, they require considerable skill in manufacture ; or they 
may either melt between the fingers before they can be introduced into 
the vagina, or they may not melt at all, and be voided unchanged. 

Colpitis Mycotica. — Vaginitis is sometimes due to micro-organisms, 
of a higher order than bacteria, which flourish in the acid vaginal dis- 
charge : such are the monilia (oidium) albicans, monilia Candida, and 
leptothrix vaginalis. 

This form of vaginitis is found most frequently in pregnant women 
with gaping vulvae, torn perineums, and vaginal prolapse. It occurs 
more often in summer than in winter, and has been attributed to damp 
dwellings. The parasites are generally conveyed to the patient by the 
air or by the fingers, especially when the latter are soiled with meal or 
flour. Similarly a woman whose infant is suffering from thrush may 
infect herself ; or again, the disease may be communicated during coitus, 
especially if the husband be diabetic. 

Symptoms. — The patients complain of intense burning, smarting, 
and itching. In the majority of cases there is little or no discharge ; 
but where discharge is present it is of an irritating, excoriating 
character. The mucous membrane is bright red, swollen, and covered 
with little white patches of varying size, but seldom larger than a pin's 
head, and excessively tender to touch. 

Treatment must be actively antiseptic. Douches will afford little or 
no relief ; it is better to introduce a speculum and fill it with solution of 
corrosive sublimate, sulphate of copper, or nitrate of silver, so that as 
it is slowly withdrawn the parts are bathed with the fluid. By this 
means a cure is usually effected in a few days. 

Emphysematous vaginitis occurs as little cysts containing gas. 
Winckle, who first described the disease, gave to it the name of colpo- 
hyperplasia cystica. 



DISEASES OF THE EXTERNAL GENITAL ORGANS 389 

In the vagina of pregnant women, sometimes in child-bed, or even in 
women who are not pregnant, hemispherical protuberances with a smooth 
soft surface, which occasionally give to the finger the emphysematous 
crepitation, are met with in regular groups from time to time, especially 
on the anterior wall, in the upper third of the vagina, and on the mucous 
membrane of the portio vaginalis. They stand upon a swollen bright 
red base, and are often surrounded by a narrow red margin. If one of 
these little vesicles be punctured it immediately collapses without any 
escape of fluid, but occasionally with the sound of escaping gas. This 
condition is classed amongst inflammations because of the attendant 
swelling and hypersecretion. 

Exfoliative vaginitis is characterised by periodical exfoliation of the 
epithelium of the membrane, and is usually associated with dysmenor- 
rhoea. It was first described by Dr. Farre in 1858 ; it is generally 
associated with and probably dependent upon hysteria. 

Diphtheritic and dysenteric vaginitis occur rarely as complications of 
these diseases. The term diphtheritic is often erroneously applied to a 
white membrane which forms in the vagina in some cases of puerperal in- 
fection ; in sloughing cancer and myoma ; and in some of the fevers, espe- 
cially measles, small-pox, and typhus. Erysipelas may also attack the 
vagina. 

Phlegmonous Peri-Vaginitis. — Here the peri-vaginal cellular tissue 
is the chief seat of the disease, and as the vaginal tube is deprived of 
its nourishment through this tissue, it necroses and is thrown off as a 
slough. This rare affection was first described by Marconnat, but its 
etiology is yet obscure. It has been seen to follow the exanthemata 
and venereal affections. 

Symptoms. — Fever, slight haemorrhages, or putrid discharge. Pain 
is always present, and was in one case very severe. The labia are 
swollen and superficially ulcerated. The vaginal mucous membrane 
is swollen and pale, discoloured and necrosed. Most reported cases 
recovered, and were not followed by as much contraction as might have 
been expected. 

The treatment is limited, in the early stage, to disinfection ; in the 
later to the prevention of contraction of the cicatrices. There is a 
much more chronic form of peri-vaginitis, associated with chronic 
syphilis, which sometimes leads to fistulous communications between 
the vagina and rectum. 

Vaginismus is a term applied to an abnormal hypersesthesia of the 
external genital organs, causing muscular spasm. It occurs chiefly in 
young, nervous, and hysterical women. It is sometimes associated with 
irritable urethra, or with a rigid hymen which has become irritated and 
inflamed. If the hymen is already ruptured the carunculae myrtiformes 
are excessively sensitive. This condition has been attributed to fissure 
of the anus ; and to incomplete coitus, resulting from imperfect erection 
and premature ejaculation. Sometimes the symptoms are due to spasm 



390 SYSTEM OF GYNECOLOGY 

of the perineal and levator ani muscles on attempted copulation. At 
other times there is a feeling of weight in the perineum ; hypochon- 
driacal symptoms are also present as a rule. A form of vaginismus, 
attended with spasm of the levator ani muscles, has been described as 
superior vaginismus ; it causes the very unpleasant complication of 
penis captivus. 

Treatment. — Where a local cause is discoverable efforts should be 
made to remove it; hydropathy, potassium bromide, cocaine, opium, 
and belladonna in suppository, have been found of benefit in removing 
the spasm : excision of the carunculse myrtiformes and gradual dilata- 
tion of the vulva may be practised; or the patient may be placed under 
an ansesthetic and the vulva forcibly dilated with the fingers. Marion 
Sims used to treat these cases by a V-shaped incision of the posterior 
wall of the vagina, and I have certainly seen benefit follow this proced- 
ure or some modification of it. Electricity has also been tried with 
some apparent benefit. 

Tumours of the Vagina. — Tumours of the vagina are of the fol- 
lowing kinds — cystoma, fibromyoma, carcinoma, sarcoma, tuberculosis. 

Simple cysts occur in the majority of cases as small tumours, from 
the size of a cherry stone to that of a walnut ; they are seldom so large 
as the fist or foetal head. Their position is as variable as their size. 
They are generally found in the lower half of the vagina, but may occur 
in any part. The origin of these cysts is not clear : in some cases they 
originate in a remnant of Mtiller's ducts ; in other cases they may be 
connected with the Wolffian or Gartner's ducts. They may arise as 
retention cysts connected with certain glands discovered by v. Preuschen. 
Others must be regarded as dilated lymphatics, or extravasations of 
blood. 

Cysts, excepting in cystic vaginitis, are generally single; but some- 
times they are multiple. They are covered by ordinary mucous mem- 
brane, which may be so thinned by expansion that the contents shine 
through ; they contain mucus either clear or milky from admixture of 
epithelium, or black or dark from admixture with blood ; in multilocu- 
lar cysts the contents are often various. 

Treatment. — Small cysts should be extirpated; larger ones should 
have their surface removed to the level of the vagina, and the cyst wall 
stitched to the vaginal mucous membrane. 

Fibroids. — In comparison with uterine myoma these tumours are 
rare. They most frequently occur in the anterior wall ; at first they 
are broad-based and sessile, but later become pedunculated. They vary 
in size from a pea to that of a foetal head or more. 

Symptoms. — Small tumours cause no symptoms ; larger ones cause 
inconvenience through their weight and pressure on surrounding struct- 
ures : they may cause a feeling of dragging, difficulty in walking and 
sitting, irritability of the bladder or difficulty in emptying it. Obstruc- 
tion arises to coitus and to child-birth. 



DISEASES OF THE EXTERNAL GENITAL ORGANS 391 

Treatment consists in operative removal. Polypi are removed by 
cutting through the pedicle with scissors or ecraseur. Sessile tumours 
should be enucleated. The cavity left may be closed by suture after all 
bleeding vessels have been ligatured ; or, if this be impracticable, it should 
be plugged with iodoform gauze. 

Carcinoma. — Primary cancer of the vagina is rare ; secondary cancer 
is very common. The former occurs as a papillomatous growth upon a 
broad, infiltrated base upon the posterior wall, or as a firm, annular 
constriction or uniform infiltration of the entire vaginal tube. 

Tlie etiology is unknown, but it usually occurs between the ages of 30 
and 60. Child-bearing has not any influence in its causation. 

The symptoms are the same as those attending cancer elsewhere. The 
patients complain of pain ; watery discharge often offensive and irritating ; 
haemorrhage, especially after coitus ; and, later, implication of glands and 
the cancerous cachexia. 

The prognosis is bad. Patients rarely seek advice until too late for 
successful extirpation ; and even when removal of the growth has been 
effected, return is almost certain. Probably the best method of operation 
in these cases is to incise the perineum transversely, to separate the vagina 
from the rectum from below, to a point above the upper margin of 
the disease, to excise the detached vaginal wall, and, finally, to close the 
wound by suture. In cases too far advanced for extirpation, the disease 
should be scraped away as far as possible with a sharp spoon and 
cauterised with the actual cautery. Great care must be taken not to 
injure the bladder or rectum, as a fistula could scarcely be closed again. 
In many cases our treatment is limited to antiseptic douching or dry 
dressing. 

Sarcoma is even rarer than primary cancer, and is remarkable for its 
occurrence in early childhood ; it has even been supposed to be congeni- 
tal. It may, however, occur at any age. It generally attacks the 
anterior wall in children, though in adults it occurs as often on the 
posterior wall. It occurs as a circumscribed tumor, a fibrosarcoma, or 
as a diffuse infiltration. The disease rapidly spreads to the bladder, 
rectum, perineum, and external genitals. 

Pathology. — Microscopically both round and spindle cells occur with 
an increase of connective tissue. The disease usually originates in the 
papillae of the vaginal mucous membrane. 

The symptoms are irregular hsemorrhages ; mucous discharge, often 
putrid ; pain ; disturbance of the bladder ; a sense of bearing down and 
wasting. 

For diagnosis a piece of the diseased structure should be excised and 
examined with the microscope. 

The prognosis is exceedingly bad ; the disease returns in spite of 
operation. Schuchhardt gives one case in which the patient remained 
free from its return for two years. 

The treatment consists in the earliest possible removal of the disease. 

Foreign Bodies in the Vagina. — A great number of foreign bodies 



392 SYSTEM OF GYNECOLOGY 

have been found in the vagina — glasses, cups, candles, reels, and the 
like, which have been introduced for sexual gratification ; also hair-pins, 
sponges, tampons, and pessaries which have been worn by patients for 
ten years and upwards, and have been completely forgotten. Entozoa 
may be introduced from the bowel; the ascaris lumbricoides, the 
oxyuris vermicularis, and the pulex irritans have been found, and in one 
case a grasshopper. Large foreign bodies compel the patients at once to 
seek medical aid; smaller ones remain to produce vaginitis with 
purulent offensive discharge mixed with blood, saprophytes, and other 
pathological micro-organisms, which cause a foetid irritating discharge 
resembling that of cancer. Not infrequently stenosis occurs in the 
vagina, just below the foreign body, with almost complete occlusion of the 
vagina ; the diagnosis can then be made by rectal examination only. 
The removal of the body is not always a simple matter ; but it is an 
absolute necessity, since its retention might cause death from putrid 
peritonitis. The first step is the antiseptic douche ; the second is to 
dilate the stricture ; the third is to remove the foreign body. Occasion- 
ally it is necessary to divide the recto-vaginal septum, which, after the 
removal of the foreign body, should be followed by immediate reunion. 
The cavity left should be thoroughly disinfected and plugged with 
gauze. 

W. Smyly. 



REFERENCES 

Diseases of the External Genital Organs — Vulvitis: — 1. J. M. Duncan. Lancet, 
1877. March 3.-2. Med. Times and Gaz. Feb. 3, 1880, p. 199. — 3. C. v. Braun. 
Wien. med. Wochensch. 1878. — 4. Kinder Wood. Med.-Chir. Trans, vol. vii. — 5. 
Parrot. Rev. de med. p. 177, 1881. — 6. Herman. Ohstet. Trans. 1883. — 7. 
Priestley. Ohstet. Trans. 1884.— 8. Tarnowsky. Cthl.f. CAir. p. 354, 1887. — 9. E. 
Luther. Vol. klin. Vort. N. F. 82, 83, 1893.-10. Wertheim. Verh. der Dtsch. 
Ges. f. Gyn. §346,1891.-11. Sanger. Verh. d. Dtsch. Ges. f. Gyn. §361,1892.— 
12. Schaffer. Verh. d. Schles. Ges. f. Vaterlandkult. Feb. 1894.— 13. J. Veit. 
Zeit. f. Gebh. ii. Gyn. Bd. xxviii. 1894. — 14. G. Klein. Monats. f. Geb. u. Gyn. Jan. 
1895. Tumours :— (Elephantiasis) : 15. M'Clintock. Dub. Journ. xxiii. 1862.-16. 
Playfair. Trans. Obstet. Soc. xix. p. 184. — 17. Peters and Klebs. Drag. Vier- 
telj., 124, § 69, 1874. (Lupus): 18 West. Dis. of Worn. p. 822, 1870. — 19. J. 
M. Duncan. Edin. Med. Journ. Dec. 1862. — 20. Huter. Dtsch. Zeitsch. f. Chir. iv. 
p. 508, 1874. — 21. Thompson. Lancet, 1892.— 22. Hegar. Gen. tuberculosa des 
Weibes, 1887. (Malignant): 23. Eberhardt. Dis. Wiirzburg, 1885. — 24. Kustner. 
Zeit. f. Gebh. u. Gyn. vii. § 70, 1881.-25. Schroeder. Zeit.f. Geb. u. Gyn. iii. 423, 
1878. — 26. Prescott Hewitt. Lancet, March 16, 1861. — 27. Robb. Johns Hopkins 
Hasp. Rep. ii. 227, 1890. —28. Thomas. N. Y. Jour. xxxi. 490, 1880. (Fibro- 
myoma) : 29. Klob. Path. Anat. d.weibl. Sexualorgane, p. 459,1864. — 30. M'Clintock. 
Dub. Jour. vol. iv. 1862.-31. A. R. Simpson. Ed. Med. Jour. 1878.— 32. J. M. 
Duncan. Med. Times and Gaz. Jan. 24, 1880. (Lipoma) : 33. Stiegele. Zeit. f. 
Chir. u. Geb. Bd. ix. p. 243, 1856. — 34. Bruntzel. Ctbl. f. Gyn. p. 626, 1882. 
(Enchondroma) : 35. Schneevogt. Ver. van het Genootschap ter Bevorde^nng d. 
Geneesen Heclkunde te Amsterdam, ii. 1, p. 67, 1885. — 36. Beigel. Der Krank. des 
iveib. Gesch. Bd. ii. p. 728. (Neuroma): 37. Simpson. Med. Times, Oct. 1859.-38. 
Kennedy. Med. Press, and Cir. June 7, 1874. (Angioma) : 39. Sanger. Ctbl. 
f. Gyn. p. 125, 1882. (Cystoma): 40. Werth. Ctbl. f. Gyn. p. 512, 1878.-41. 
Galabin. Obstet. Trans, p. 54, 1884.-42. Wiltshire Obstet. Trans. Lond. 1881. 
Pruritus Vulvae:- 43. L. Mayer. Mon. f. Geb. July 1862.— 44. Edis. B.M. J. Jau. 



DISPLACEMENTS OF THE UTERUS 393 

11, 1868. —45. ScHROEDER. Cthl. /. Gyn. p. 805, 1884. Kraurosis Vulvae: — 46. 
Breisky. Zeit. f. Heilk. vi. 69, 1885.-47. Orthmann. Zeit. f. Geb. u. Gyn. xix. 
§283, 1890. Vaginitis: — 48. DoDERLEiN. Das Scheidensekret. Leipzig, 1892.— 49. C 
RuGE. Zeit. f. Gehur.u. Gyn. Bd. iv. 1879.-50. Eppinger. Prag. Zeit. f. Hlk. iii. 
153. — 51. E. Frankbl. Virch. Arch, xcix, p. 251, 1883. — 52. Chiari. Prag. Zeit. 
f. Hlk. vi. § 81, 1885.-53. Birch. Hirsch. Lehrbuch, ii. p. 794, 1887.-54. Kummel. 
Virch. Arch. cxiv. p. 429, 1888.-55. V. Herff. Volk. Sain, cxxxvii. 1895.-56. 
WiNKEL. Arch. f. Gyn. Bd. ii. p. 383, 1871. Vaginismus : —57. J. M. Duncan. 
Clin. Led. on Bis. of W. p. 142, 1883. —58. M. Sims. Ohstet. Trans, vol. iii. p. 356. 
1862.-59. J. Y. Simpson. Dis. of Worn. p. 284, 1872.-60. Budin. Progres Med. 
Paris, ix. 1887. Vaginal New Growths : —61. O. Hemming. Edin. Med. and Surg. 
Journ. — 62. G. Veit. Krank. des weibl. Gesch. 1867. — 63. Winkel. Lehrb. Frauenk. 
§112,1890.-64. Klebs. Path. Anat. 1876. — 65. Hall Davis. Trans. Obstet. Soc. 
1867. — 66. V. Preuschen. Virch. Arch. Bd. Ixx. 1877. — 67. Cullingworth. Obstet. 
Journ. of Gt. Britain and Ireland, Oct. 1879. — 68. J. M. Duncan. 3fed. Times and 
Gaz. 1880. — 69. M'Clintock. Clin. Memoirs of Bis. of Worn. — 70. Paget. Led. 
on Surg. Path. — 71. Barnes. Obstet. Trans, vol. xiv. p. 309. — 72. Hegar. Genital- 
tuberculosa des Weib. 1887.-73. Strassman. Ctbl. f. (??/n. § 825, 1891.-74. Badly. 
Med. and Surg. Reporter, xlii. p. 199. — 75. Klein. Zeit. f. Geb. u. Gyn. xviii. § 82, 
1890. Foreign Bodies : — 76. Diefenbach. "Fremdkorper in d. weibl. Gen. u. Harn- 
blase," Bis. Berlin, 1890.-77. Klebs. Handb. d. path. Anat. Bd. i. p. 976.-78. 
Pearse. Brit. Med. Journ. 28th June 1873.-79. Carter. Obstet. Trans, p. 34, 
1880. 

w. s. 



DISPLACEMENTS OF THE UTERUS 

Even in perfectly normal conditions tlie uterus is liable to vary greatly 
in its relations to the pelvic cavity in which it lies. These relations 
are modified by its own functional activities, as well as by the distension 
and evacuation of the adjacent viscera. We may consider it as placed 
in the pelvis : (A) as regards its Level, so that the fundus corresponds 
more or less to the plane of the brim, and the os externum points to 
the coccyx in the plane of the ischial spines ; (B) as regards its Position, 
so that it lies nearly midway between the symphysis pubis and sacrum, 
and between the two sides of the pelvis ; and (G) as regards its Direction, 
so that its axis corresponds more or less to the axis of the pelvis. So 
we may find it in moderate degrees of distension of the bladder and 
rectum. Let these organs, however, be fully distended, and the uterus 
will be raised above the level which we have assigned to it. Let the 
bladder alone be distended, and the uterus will be carried back beyond 
the middle line of the pelvis. Let the bladder be emptied, and the 
uterus will fall forward so that its fundus comes close to the symphysis 
pubis. It is in this position that it is most frequently found on bimanual 
examination. 

With this wide range of physiological mobility it keeps its place by 
virtue of : (i.) the insertion of the supravaginal portion of the cervix in 
the upper end of the vagina, where it rests upon the tip of the sacrum 
and coccyx in the pelvic floor ; (ii.) the action of the utero-sacral liga- 
ments, which keep the isthmus in its proper relation to the upper part of 



394 SYSTEM OF GYNECOLOGY 

the hollow of the sacrum; (iii.) the utero-vesicle ligaments, which main- 
tain its relation to the bladder and symphysis pubis ; (iv.) the broad 
ligaments on each side, which especially regulate its lateral movements ; 
and (v.) the round ligaments, which keep the fundus directed upward and 
forward towards the inguinal canals. When it fails to retain its equi- 
librium, either in the way of excess of movement beyond its normal 
range, or of losing the power to recover its normal relations, its displace- 
ments become pathological, and give rise to troubles that lead the patient 
to seek for medical advice. 

In a large proportion of cases the displacement will be found to be 
not simple, but compound. Thus, where there is a downward deviation 
from the ordinary level, and the uterus is prolapsed, there is usually also 
a loss of its normal direction, and the uterus is retroverted. But it is 
the downward displacement that is the most important element in the 
case, and which most urgently calls for rectification. Again, in many 
cases an anteflexed uterus may be found lying close to the hollow of the 
sacrum in a state of retroposition ; and it may require careful analysis of 
the conditions before the practitioner can decide which of the two devia- 
tions — the deviation in direction or in position — is the more chargeable 
with the patient's sufferings. We will study, however, the different 
displacements in succession and consider : — 



A. Deviations from the Normal Level 

The uterus may be found moved beyond the planes of the pelvis 
within which it normally ranges either Upwards or Downwards. 

I. Ascent of the Uterus. — In the elevations or upward displace- 
ments of the uterus, the organ is lifted off the pelvic floor, and the fundus 
rises above the pelvic brim so as to be accommodated to a greater or less 
extent in the abdominal cavity. The gravid uterus, say from the third 
month onwards, grows gradually and at a steady rate higher and higher 
in the abdomen. So when the unimpregnated uterus becomes the seat 
of a large myoma, it may have become largely an abdominal organ before 
it comes under observation. When a tubal gestation goes on develop- 
ing beyond the early months; when an ovarian or parovarian tumour 
grows down into the broad ligament or becomes fixed behind the uterus ; 
when an effusion or extravasation is encapsuled in the pouch of Douglas; 
or a tumour grows in the rectal wall ; — in all these and similar cases the 
uterus may be lifted or pushed upwards : and even in some peritonitic 
cases the fundus may have acquired adhesions which drag it towards the 
abdomen. The ascent of the uterus under such circumstances, however, is 
only a bye-phenomenon. It may be of vital importance to recognise the 
abnormal position, and our successful treatment of the patient may 
depend on its detection ; but elevation of the uterus does not present 
itself to us as an isolated occurrence, and the symptoms associated with 
it are subsidiary to those of the condition which brought it about. It 



DISPLACEMENTS OF THE UTERUS 395 

is quite otherwise with the downward displacements, which we now 
proceed to consider. 

II. Descent of the Uterus. — Prolapsus or procidentia uteri — fall- 
ing down or protrusion of the womb — are names that have been used to 
express the downward displacement of the uterus, which leads to its escape 
from the pelvic cavity till it comes to lie externally to the pudenda. It 
must be recognised at once that here the dislocation of the uterus is not 
an isolated phenomenon. As the organ sinks in the pelvis it drags with it 
its adnexa, the Fallopian tubes and ovaries : its depression is followed by 
depression of the superincumbent coils of the intestines ; and, even if 
in the early stage of the process the vaginal walls with the bladder and 
rectum may have retained somewhat of their normal position, in the 
more advanced stages these have all moved downwards to such an extent 
that the vagina has become completely inverted : so that we have to do 
with a hernial process, the pelvic contents escaping through the oblique 
fissure in the pelvic floor, which we think of as the vaginal canal, until 
we have a sac, the covering of which is formed by the inverted vaginal 
w^alls, and the contents of which consist of the body of the uterus and 
the adjacent viscera. The displacement may begin at the upper, uterine 
extremity of the fissure, or at the lower, pudendal extremity ; or the 
favouring conditions may operate simultaneously throughout the whole 
pelvic floor. But in any case the displacement of the uterus is the 
central element in the disturbance ; its functional troubles are prom- 
inent among the attendant symptoms ; and the treatment must have 
regard to its reposition and its retention in its proper place. 

The displacement may be met with at different stages, so that a 
distinction has been drawn between the different degrees of descent. 

Degrees of Descent. — i. In the simplest cases the uterus has only 
sunk downwards to a slight degree from its ordinary level, the fundus 
lying distinctly below the brim of the pelvis, and the os low on the pelvic 
floor ; but it retains its ordinary position in the middle of the pelvis, and 
the fundus has its ordinary anterior inclination, ii. In a second group 
of cases, wdiere the prolapse is still incomplete, the uterus has sunk still 
lower, with the os resting on the anterior margin of the perineum, or ap- 
pearing at the pudendal fissure, and the fundus is found at a varying 
height according to the size of the organ. In this variety the uterus has 
undergone a change in the direction of its axis, and has fallen backwards 
towards the hollow of the sacrum, so that it is not only in a state of 
prolapse, but at the same time of retroversion or retroflexion, iii. In 
cases of complete descent the whole organ has sunk so low that it 
projects within the inverted vagina completely beyond the pudendal 
orifice ; and in this situation the body is usually found retroverted, though 
in rare cases the fundus may be directed upwards or forwards. It 
has sometimes been proposed to distinguish the varying degrees of de- 
scent by speaking of the incomplete varieties as cases of prolapsus, and 
the complete variety as procidentia uteri. The names, however, are not 
distinctive ; and whether we call the descent prolapse or procidence, we 



396 SYSTEM OF GYNECOLOGY 

must distinguish between the cases where the uterus is still within the 
vaginal cavity, and those where it is entirely extruded, by speaking of 
the former as incomplete and the latter as complete prolapse. In the 
case of incomplete prolapse, we have the two sub-varieties : (a) incom- 
plete prolapse of normally inclined uterus; and (6) incomplete prolapse 
of retroverted uterus. In the case of complete prolapse the direction of 
the uterus is of minor moment. 

Pathological Anatomy. — If we look more carefully at the structures 
protruding through the vulva, we shall find we have to do with different 
elements of the pelvic contents in different cases. In all the cases the 
vaginal w^alls have become dislocated, but as regards other viscera we 
find in some — 

i. Chiejly displacement of uterus. — The tumour projecting through 
the vulva is covered completely with the inverted walls of the vagina, 
which have lost their rugosities and present a smooth appearance. The 
OS uteri may be seen at the lower anterior part, where the cervix barely 
projects beyond the general surface of the tumour ; and through the 
walls, the body of the uterus with its adnexa, and occasionally some 
intestinal coils, can be felt occupying the hernial sac. 

ii. Chiejly displacement of bladder. — Sometimes the projecting struct- 
ure is constituted mainly by the descent of the anterior wall of the 
vagina, carrying with it the back wall of the bladder. The case is one of 
cystocele. In this condition the uterus may be only in the first stage 
of incomplete descent, and remain functionally active. If the uterus 
become gravid the cystocele may become aggravated, and be a source of 
trouble during pregnancy and labour, whilst the uterine displacement is 
for the time undone. This prolapse of the anterior vaginal wall, how- 
ever, is more apt to become associated with hypertrophic changes in the 
cervix uteri which lead to more complete prolapse of the whole organ. 

iii. Chiefly displacement of rectum. — In rarer instances it is the back 
wall of the vagina that projects through the vulva. The case is one of 
rectocele, so-called, or proctocele. 

iv. Cystocele with hypertrophy of intermediate portion of cervix uteri. 
— The circumstance that the vaginal mucosa lays hold of the cervix low 
down in front at about one-third of an inch from the anterior lip, whilst 
behind it passes up to within about one-third of an inch from the isthmus, 
has led to the convenient distinction of the cervix into the three seg- 
ments. Below we have the vaginal or infravaginal portion, lying 
entirely free in the vaginal cavity below the level of the anterior for- 
nix ; above we have the supravaginal portion embraced by parametrium 
and lying entirely above the level of the posterior fornix ; between 
these is the intermediate portion lying above the level of the anterior, 
and below the level of the posterior fornix. On its posterior aspect 
this intermediate portion lies free in the vagina ; its anterior surface 
lies above the vaginal reflection, and is in contact with the areolar 
tissue which separates it from the bladder wall. This intermediate 
portion undergoes a remarkable degree of hypertrophy and elongation in 



DISPLACEMENTS OF THE UTERUS 



397 



cases where the anterior wall of the vagina has been displaced. The 
vesico-vaginal septum that has been exposed through the vulva becomes 
congested and thickened, and is the seat of a hyperplasy that extends to 
the portion of the cervix with which it is in intimate vascular relations. 

V. Cystocele and Proctocele, tvith hypertrophy of the ivhole siiprob- 
vaginal portion. — In many cases where the cystocele alone exists in a 
marked degree, the hypertrophy may affect the whole supravaginal 
portion of the cervix. Such a hypertrophy is more certain to be pro- 
duced when the posterior as well as the anterior vaginal wall has escaped 
through the vulva. In such a case the protruded mass has a large seg- 
ment of the bladder in front and a rectal pouch behind ; and is felt to 
contain only the elongated cervix and isthmus of the uterus, whilst the 
fundus and its adnexa are still within the pelvic cavity. 

Causes of Prolapsus Uteri. — AVe have seen that the uterus maintains 
its normal level by virtue of a balance between the structures that sustain 
it and the forces that tend to depress it. We must look, therefore, for 
the causes of its permanent descent either, on the one hand, to conditions 
that weaken its supports, or on the other to conditions that increase the 
strain upon them. These conditions are (a) Passive, and {h) Active. Fre- 
quently enough these conditions are simultaneously operative in both 
directions. 

(a) Passive causes. — These are to be found in loss of retentive power 
of the uterine supports, and foremost among the defects that lead to 
descent of the uterus we must place : — 

i. Faults in the perineum. — The integrity of the perineum may be 
seriously impaired, and yet the uterus maintain its normal place. The 
whole of the structures between the lower third of the vagina and the 
rectum may be found lacerated to such an extent that the patient is 
unable to control the action of the bowels, and comes to seek relief 
because of this trouble. In such a case the uterus may be found at its 
normal level, the other sustaining structures being of sufficient strength 
and tonicity to maintain it in place ; or inflammatory or cicatricial 
changes may have impaired its mobility. As a rule, however, damage of 
the perineum or perineal body is a prime element in the weakening of the 
pelvic floor that eventuates in herniation of the pelvic contents. This 
damage is usually inflicted during labour, and may take the form either 
(a) of laceration beginning at the fourchette, or on the mucous surface, or 
even on the cutaneous surface, and running more or less deeply through all 
the tissues to or into the anal and rectal canal ; or (/?) of diastasis of the 
muscular and fascial tissues that meet in the perineal body, and lie 
between the mucous membrane and the skin. In the latter case no 
cicatrix is to be seen behind the vaginal orifice. The mucous lining 
and the skin covering of the perineum have been dilated without being 
fissured, and the structures seem to be entire ; but when the perineum is 
grasped between the finger and thumb, or is stretched on two fingers 
introduced into the vagina, it is felt to be thin and relaxed, and incapable 
of offering any effective resistance to the pressure brought to bear on it 



398 SYSTEM OF GYNECOLOGY 

from above. Where the perineum has been thus torn or strained, so that it 
ceases to afford adequate support to the superjacent structures, the first 
stage of a displacement is seen in the projection of the anterior vaginal 
wall through the patulous orifice ; and where other causes are in operation 
tending to a descent of the uterus, the displacement comes about the 
more easily and rapidly from the absence of the resistance offered to it 
by the healthy perineum. 

ii. Faults in the vaginal walls. — We have seen that it is through the 
vaginal canal that the uterus becomes herniated. It is obvious that the 
varying condition of the vaginal walls will modify the proclivity to the 
uterine descent. In the cases where the uterus keeps its place, notwith- 
standing that the perineum is deeply fissured, the anterior vaginal wall 
and the posterior wall above the seat of laceration are usually found to 
be healthy. The rugse are well preserved ; the submucous muscular and 
areolar tissues have retained their tonicity ; and freedom from all the 
leucorrhoeal discharges associated with colpitis allows the walls to retain 
their normal degree of apposition. Where, on the other hand, the 
vaginal walls have become so distended as to have lost something of their 
tonicity, and where, in addition, the surfaces are bathed with a discharge 
due to inflammatory and congestive processes, the walls readily become 
separated, and the inversion of the canal is facilitated either from below 
or above. That it more frequently begins from below is due to the 
frequent initiation of the mischief by the perineal defect which leads to 
exposure of the lower part of the anterior wall. Every mucous membrane 
subjected to unusual exposure is apt to become the seat of inflammatory 
changes, as may be seen in ectropion of the palpebral conjunctiva, or of 
the cervical endometrium ; hence the perineal laceration leading to 
exposure of the anterior vaginal wall, is usually attended with chronic 
inflammatory changes, that lead to genera! colpitis with free discharge 
and thickening of the tissues that favour the production, first of cysto- 
cele and then of a more complete prolapse. 

iii. Faults in uterine ligaments. — In some instances we trace the 
descent of the uterus, not so much to loss of power in the structures that 
support it from below, as to inefiiciency of the structures that should 
retain it above. It is the relaxation of all its ligaments, utero-sacral 
and utero-vesical, broad and round, subsisting for some time after parturi- 
tion, that facilitates the sinking down of the uterus which is so apt to be 
initiated during the puerperium. When these ligaments remain per- 
manently relaxed and strained a more decided and permanent descent of 
the uterus ensues. 

iv. Faults in the cellular tissues. — In the areolar tissues surrounding 
the pelvic organs, and filling in the interspaces between the layers of 
fascia in the different muscular planes, there is found in healthy women 
a considerable amount of fat. When absorption of this adipose deposit 
takes place, as in patients who are the subjects of wasting disease, and in 
some women at the climacteric period, a tendency to downward displace- 
ment of the uterus and vaginal walls is distinctly traceable. This 



DISPLACEMENTS OF THE UTERUS 399 

prolapse may be partly due to weakening of the ligaments, which is not 
unlikely to be present under such circumstances, but the absence of the 
normal fatty padding of the pelvis contributes in a notable degree to the 
result. 

V. Faults in the pelvis. — We can understand that the contraction of 
the brim and expansion of the outlet, characteristic of the rickety pelvis, 
should favour the descent of the uterus ; so that we sometimes find pro- 
lapsus uteri in virgins associated with this form of pelvis. In a secondary 
sense this, and other varieties of malformation, become causes of prolapsus 
in the damage that may be done during labour by the operative pro- 
cedures which they render necessar^^ Besides, these changes in con- 
figuration are occasionally associated with changes in the inclination of 
the pelvis; and whenever the inclination of the pelvis is continuously 
disturbed, and the plane of the brim, instead of meeting the horizon at 
an angle of about bh°^ becomes more or less parallel to it, downward 
displacements of the uterus are favoured. Such change from the normal 
inclination occurs in elderly women in whom the anterior curve of the 
lumbar vertebrae is lost, and in others whose avocations keep them for 
long periods of time in such attitudes that the promontory of the sacrum, 
instead of being four inches above the level of the upper margin of the 
pubic symphysis, is nearly in the same horizontal plane. 

ih) Active causes, — Among the conditions that operate more directly 
in producing prolapsus uteri we note : — 

i. Enlargements of the uterus itself. — In the early weeks of pregnancy, 
when the uterus begins to grow, it sinks slightly, so that the os is found 
at a somewhat lower level than in the case of the non-gravid organ. 
During the puerperium the descent of the uterus, which is rendered possi- 
ble by the relaxation of its ligaments, is promoted by the increase in its 
own weight, which persists until its involution is complete. When the 
involution is interrupted, and the uterus remains enlarged in conse- 
quence of the subinvolution, or when it is hypertrophied as a result 
of chronic metritis, or from the development of neoplasms in its walls, 
the increase in weight of the organ is among the factors that tend to its 
depression. For though the hypertrophies of the uterus may sometimes 
be a result of congestive processes due to its displacement, in many cases 
the hypertrophy initiates the descent, and in any case it favours it. 

ii. Distension of neighbouring organs. — Habitual over-distension of 
the bladder necessarily causes undue pressure on the pelvic floor and 
undue strain on the ligaments of the uterus with which the bladder is in 
such intimate relation ; it must be regarded, therefore, as among the 
causes of uterine displacement. In a less degree habitual constipation 
has a similar effect. 

iii. Increase of supra-pelvic pressure. — Of the causes that work 
actively towards the production of prolapsus uteri, however, the greatest 
importance is to be attached to those which produce their effect by 
increasing the pressure that is more or less continuously exerted on the 
pelvic contents. This supra-pelvic pressure is increased in cases of (a) 



400 SYSTEM OF GYNECOLOGY 

Relaxation of the abdominal walls. Such relaxation is especially apt to 
occur in multiparous women, especially where the walls have been over- 
stretched from the presence of unusually large children, or twins, or 
hydramnios. It may also be found in women who have been subjected 
to laparotomy for a large ovarian tumour. The abdominal walls are soft 
and thin, the muscular layers have lost their tonicity, and the so-called 
" retentive power " of the abdomen is impaired. The abdominal viscera, 
instead of being retained in their normal relations, tend to sink down- 
wards ; and so there comes about a continuous pressure on the pelvic 
viscera, which promotes herniation through the pelvic floor. (/3) In some 
cases the supra-pelvic pressure is increased from the presence of tumours 
in the abdominal cavity, or of ascitic accumulation in the peritoneal 
sac. More frequently it results from (y) Improper kinds of dress ; as 
for example, where the waist is kept constricted by corsets too tightly 
laced, or heavy clothing is supported on bands round the abdomen. 
(S) When a woman is under the necessity of making strong or long- 
continued muscular exertions, the pressure tells upon the pelvic con- 
tents ; and in cases where prolapsus uteri is said to have occurred sud- 
denly the displacement is usually attributed to some severe voluntary 
effort, or to an accident attended with strong muscular effort. 

In considering the causes of prolapsus uteri we have to remember 
that the process of descent is a gradual one. Cases are met with from 
time to time where the patient has become suddenly aware of the mis- 
chief, and she may tell us that the protrusion was the result of an in- 
jury or strain. But when we inquire more carefully into the history, we 
recognise that, though the last stage of the displacement came on thus 
rapidly, there had been previous indications of disturbance ; and when 
we make our physical investigation we find traces of long-standing change 
in the pelvic structures. 

We have to keep in view, further, that we have to do, not with the 
effect of one of the above-named causes alone and independently, or 
even of one of the groups of causes, but with the combined influence of 
several of them acting continuously and for long periods. The women 
who are most subject to this displacement belong to the working classes ; 
and in any individual sufferer the mischief is likely to have begun after a 
confinement attended by damage to the perineum. The patient, it may 
be, got up on the second or third day, and had to attend to her child and 
do her household work ; or she may even have been obliged to follow 
some bread-winning avocation, whilst the womb was still large and 
its ligaments still relaxed. The passive conditions and the active 
causes conjoin in such a case to cause the displacement ; if they operate 
month after month, and year after year, perhaps with aggravations from 
succeeding pregnancies, they inevitably produce a complete prolapse. 
The influence of any one of the factors may be slight; but it is 
associated with others which may have arisen independently; and 
their conjoint influence continues throughout long periods. Hence we 
cannot learn much of the production of prolapsus uteri by experiment 



DISPLACEMENTS OF THE UTERUS 401 

on the amount of force required to pull the os down to the vulva, and 
to bring it outside the oritice. 

Complications. — Before proceeding to consider the symptoms and 
diagnosis of prolapsus, we must note that the displacement is constantly 
complicated with morbid changes in the displaced structures. 

i. In the litems. — Not only is the uterus, that has descended from its 
normal level, apt to be displaced backwards, it is commonly also the 
subject of a marked degree of hypertrophy. The hypertrophy may 
chiefly affect the body of the uterus. The organ may have been from the 
first in the state of subinvolution that so frequently gives a proclivity to 
displacement; or a chronic congestive metritis may have taken place 
during the course of its descent. All the walls are thickened and 
indurated, and the endometrium is expanded and vascular ; until the 
menopause sets in, a patient with a prolapsed uterus is thus the subject 
of constant endometritis. In other cases, and more frequently, the 
inflammatory process is not confined to the body of the uterus ; the cervix 
also is hypertrophied. The resulting elongation of the cervix may be 
found affecting the supravaginal and intermediate portions, so that the 
canal is more than double its ordinary length ; whilst the anterior lip 
barely projects beyond the level of the anterior fornix. This state of 
matters obtains where the mischief has begun with exposure of the 
anterior vaginal wall from incompetence of the perineum. In other 
instances we have to do with a hypertrophy of the infravaginal portion 
of the cervix. The two lips of the os are usually found distinctly 
separated as a result of fissuring during labour, and both lips may 
be found thickened and elongated. If one lip be predominantly 
affected it is likely to be the anterior. This hypertrophy of the 
cervix is carefully to be distinguished from another variety of elonga- 
tion of the infravaginal portion of the cervix uteri, which may be 
congenital in its origin, and in which such an elongation of the infra- 
vaginal portion exists, that the external orifice may appear at the vulva or 
even project beyond it, whilst yet the fundus of the unaltered body of 
the uterus retains its normal place at the pelvic brim. In the different 
forms of cervical hypertrophy the lining membrane shares in the growth 
and vascularity, so that we constantly find a catarrhal endometritis, both 
cervical and corporeal. The endocervical catarrh is likely to extend 
through the ectropic orifice, so that we frequently see catarrhal patches 
on the external surface of the lips ; and when the prolapse has existed 
for some time in a complete form, the eroded surfaces are usually 
covered with a diphtheroid pellicle. It is noteworthy that the lids 
of the procident uterus, so subject to simple inflammatory changes, 
very rarely become the seat of cancerous disease. ISTow and again an 
epithelioma is found in the protruded cervix, usually in women well past 
the menopause; but procidence of the ragged os of a multipara seems to 
confer on it a certain immunity from malignant degeneration. 

ii. In the vagina. — Whilst the herniation is still in progress, the 
vaginal walls are in a catarrhal condition and covered with moisture. 

2d 



402 SYSTEM OF GYNECOLOGY 

When it is complete the surfaces that have become smoothed and 
deprived of their rugosities become perfectly dry ; and in cases of long- 
standing eversion, the investing epithelium takes on in places the appear- 
ance of the epidermis of the skin. Eroded surfaces are not infrequently 
found in the neighbourhood of the cervix uteri covered, like those on the 
cervix, with a grayish shining pellicle. Very rarely ulcerative processes 
affect it more deeply, or an epitheliomatous degeneration may occur ; but 
these are more likely to result from the action of ill-adjusted pessaries 
than from the long-continued displacement. 

iii. In the bladder. — Imperfect evacuations of the distorted bladder 
are apt to lead eventually to cystitis; and in the diverticulum that 
pouches through the vaginal orifice below the level of the meatus 
urinarius concretions occasionally form. I have removed three vesical 
calculi from such a displaced bladder, complicating prolapsus uteri, which 
had formed in a woman from a district where stone in the bladder is 
almost unknown. 

iv. In the rectum. — The rectum mg^ be the seat of irritation and of 
undue lodgment of fsecal matter where the pouch of the rectocele pro- 
jects distinctly below the anal aperture. Sometimes prolapsus recti is 
found in a patient with prolapsus uteri. 

V. In the pelvic peritoneum. — As the appendages of the uterus follow 
it in its displacement, so they are likely to share in its inflammatory 
changes. The most important of the intrapelvic inflammations, however, 
to be noted in connection with descent of the uterus, is that which affects 
the pelvic peritoneum. When pelvic peritonitis is set up in this hernial 
sac it is apt to lead to adhesions of the apposed surfaces of the viscera in 
their distorted relations, and any attempt at reposition in such circum- 
stances may be attended not only with suffering, but with danger to the 
patient. 

Symptoms. — The symptoms that arise are due partly to the displace- 
ment, and partly to the attendant changes in the uterus and adjacent 
organs. 

i. Disturbance of uterine functions. — The patient may have menor- 
rhagia due to the endometritis. She has commonly leucorrhoea whilst the 
descent is in progress, and this discharge lessens or disappears when the 
prolapsus is complete. Conception may occur, and the displacements 
may prove troublesome during pregnancy or labour. As a rule the pa- 
tient's reproductive power is lessened, and she has acquired sterility. 

ii. Disturbance of vesical or rectal functions. — The patient may have 
frequent desire for micturition or difficulty in securing complete evacu- 
ation of the bladder or the rectum. 

iii. General pelvic disturbance. — She may have difficulty in walking 
or in working with a mass protruded between the thighs. Even in the 
incomplete stages she may have a sense of weight and dragging in the 
loins or groins. In many cases all that the patient complains of is 
the presence of the uterus at the vulva or outside of it. 

Physical Diagnosis. — When a patient comes to us complaining of a 



DISPLACEMENTS OF THE UTERUS 403 

falling of the womb, we may find her diagnosis of her own malady to be 
correct. Sometimes, instead of prolapsus uteri, we may find another 
displacement, such as retroversion or even inversion ; or we may find 
that an intra-uterine fibroid has become pediculated, and is in course of 
extrusion through the canals. The body that has appeared at the vulva 
may be a mucous polypus from the cervix ; or indeed it may be the cer- 
vix itself in a condition of hypertrophic elongation. There may be 
only cystocele or rectocele, without uterine dislocation ; or a tumour 
growing from the vaginal wall may project through the vulva. The 
supposed fallen womb may even prove to be a swelling in some part 
of the external pudenda, such as a neoplasm or cystic accumulation, or 
simple hypertrophy ; such was the case of a young lady, in whom the 
nymphse were unusually long and dependent, whose mother thought 
her to be the subject of prolapsus uteri. 

Complete prolapse of the uterus is usually very easily recognised on 
Inspection. Hanging from the vulva between the patient's thighs is seen 
a mass, the size of a fist, pink in hue, or more purple if the tumour be 
congested, with a smooth surface except when erosive patches are present, 
and presenting at its lower anterior aspect the external orifice of the 
uterus. Around the os the labia sometimes form a projection; often it 
is difficult to trace the line of demarcation between the cervix and the 
vaginal wall. When the herniated mass is grasped between the fingers 
and thumb the outline of the entire uterus may sometimes be felt within. 
In other cases one feels only the elongated supravaginal portion of the 
cervix, round and hard ; and the bimanual examination has to be made to 
ascertain the position and direction of the body of the uterus. The sound 
will at once distinguish the os uteri from a fissure in a fibroid tumour 
that might have descended to the vulva ; and carried up through the 
canal the sound will give fuller information as to the length and direction 
of the uterus and the condition of its parietes. The sound (or a catheter) 
should further be used to determine the direction of the urethra and the 
exact relations of the bladder cavity ; and a finger in the rectum adds 
to our knowledge of the size and place of the uterus, and demonstrates 
the degree of pouching that has affected the bowel itself. 

In cases of incomplete prolapse, when we make inspection and tell the 
patient to bear down, we can see the unusual mobility of the anterior 
vaginal wall, and recognise the os as it becomes depressed towards the 
vulva ; and the bimanual examination reveals to us the relations which 
the uterus has assumed in the lower part of the pelvis. In some cases the 
displacement, which is complete when the patient is in the upright post- 
ure, disappears when she lies on her back. Then the patient can be 
made to expel the womb by a downbearing effort ; or it can readily be 
brought down by traction on the anterior lip of the os. We can thus 
demonstrate, as it were, the mechanism of the herniation. In our 
examination Ave have to keep in view not merely the displacement, but 
also the complications that may attend it ; and we may see occurring 
rapidly the displacement which came about gradually under the com- 



404 SYSTEM OF GYNECOLOGY 

bined and protracted action of the various factors. Through the patulous 
vulva the anterior vaginal wall is exposed ; as the patient bears down, 
or as we make supra-pubic pressure through the abdominal walls, the 
vesico-vaginal septum is seen to descend until the anterior fornix vaginse 
comes through the pudendal aperture, bringing with it the cervix uteri. 
First the anterior and then the posterior lip of the os externum appears ; 
and, after the uterus has escaped, the posterior wall of the vagina becomes 
inverted, and the prolapsus is complete. 

Prognosis. — When the uterus has sunk definitely and for some time 
from its normal level, it has no natural tendency to recover its proper 
place. Two physiological conditions may modify the course of the 
mischief. 

i. Injluence of pregnancy. — If the patient become pregnant, and due 
care be taken to prevent abortion or aggravation of the trouble during 
the first three months, she is likely to be freed from all the discomforts 
of prolapse ; as the uterus from this time onwards rises out of the pel- 
vis and becomes an abdominal organ. Sometimes by good management 
of the labour and the puerperium, the involution of the uterus may be 
so perfectly secured, and the tonicity of its ligaments so far restored, 
that at least a partial cure may be attained. On the other hand it more 
frequently happens that the displacement recurs after the patient gets 
up ; it may be, in an aggravated degree. 

ii. Injluence of the menopause. — At the menopause the herniated 
organs usually undergo the ordinary process of senile atrophy that will 
lead to a diminution in the size of the swelling and relief from some of 
the attendant symptoms. The relaxation of the ligaments and loss of 
the fatty padding of the pelvis incidental to this period of life some- 
times, however, allows of further descent of the uterus ; so that now the 
patient applies for relief for the first time : and it must never be forgot- 
ten, in the cases where pessaries have been long worn in the vagina, that 
the shrinkage and loss of vitality in the walls may lead to ulcerative 
processes to which the tissues had shown no previous tendency. 

Treatment. — A prudent practitioner in his midwifery practice will 
keep in mind the risks to which a woman is subject who comes out of her 
confinement with a damaged perineum, relaxed uterine ligaments, and 
subinvolution of the uterus. He will note during labour the conditions 
that endanger the perineum and seek to avert its laceration. Where 
laceration has occurred he will see to its immediate repair, bringing 
together the raw surfaces with sutures at the close of the third stage, or 
within twelve hours thereafter. He will guide the convalescence, and see 
that no undue exertions are allowed until the ligaments have recovered 
their tone, and the uterus is restored to its non-gravid dimensions. By 
such prophylactic measures he saves his patient from the beginnings of a 
displacement which may cause little disturbance at first, but which v/ill 
go on to increased distress, and may be a source of trouble for a lifetime. 

Where the prolapsus uteri is complete the indication for treatment 
is twofold : to reduce ; and to retain the displaced organ. 



DISPLACEMENTS OF THE UTERUS 405 

i. Reduction of the uterus. — The uterus, which is completely prolapsed 
when the patient is in the upright position, is often reduced of itself when 
she lies down 5 so far, at any rate, as to disappear within the vaginal ori- 
fice ; or when not spontaneously replaced it may be made to return with 
the gentlest amount of pressure. Occasionally some degree of force must 
be exerted ; and in performing taxis in such cases the practitioner has to 
keep in mind the manner in which the herniation occurred, and to seek 
to replace the structures in the reverse order to that in which they 
descended. He begins with the posterior wall of the vagina, which was 
the last to escape, and presses it past the perineum. The uterus follows, 
first the posterior and then the anterior lip of the cervix. Last of all the 
anterior vaginal wall is replaced. It is especially in such cases that the 
anterior wall is found to have become greatly thickened, widened, and 
indurated in its texture. In some instances the prolapsed mass is so 
swollen and congested that the patient must be kept at rest for some days 
before the reduction can be safely effected ; and during that time she may 
use a hot sitz bath, or have a stream of hot water made to play over the 
tissues two or three times a day, so as to reduce the hypersemia. It may 
even be necessary, for this purpose, to make some scarifications on the 
surface to relieve the vascular tension. Where an active peritonitis is 
present, or peritonitic adhesions have formed among the displaced viscera, 
rude or rapid manipulation would be attended with danger ; and prolonged 
antiphlogistic measures should be employed before the attempt is made to 
replace the organs. In all cases the reposition should not only be preceded, 
but also followed b}^ the adoption of an antiphlogistic treatment calcu- 
lated to lessen the uterine hypertrophy, and of measures calculated to 
restore the tonicity of the pelvic tissues. With this view it may be 
necessary to curette the uterus, and to apply iodine and carbolic acid to 
the interior ; to administer ergot and quinine, or such deobstruents as the 
iodide and bromide of potassium ; to use such waters as those of Kreuz- 
nach, Krankenheil, Ems, or Kissingen, and to enjoin the use of hot and 
astringent douches. 

Massage has been employed for the relief of this as of other pelvic 
mischiefs ; and Thure Brandt, who by his successful treatment of various 
uterine disorders has induced some members of the profession to adopt 
the practice in recent years, has suggested a mode of reduction of the 
prolapsed uterus which has been followed by various gynaecologists in 
different countries with encouraging results. The patient under treat- 
ment is placed on her back with her knees bent up ; and, while an assistant 
pushes up the pelvic organs through the vagina, the operator lays hold 
of the body of the uterus with the finger-tips of his two hands pressed 
through the abdominal walls at the pelvic brim. When he feels that he 
has the uterus between his hands, with a kind of wriggling movement 
he pulls it upwards as far as possible into the abdominal cavity. This 
uplifting of the organ has to be repeated daily, or at short intervals ; and 
the congestive processes are at the same time relieved by friction applied 
to the uterus and its adnexa through the uterine parietes. But, besides 



4o6 SYSTEM OF GYNECOLOGY 

acting thus on the uterus and appendages, the operator, placing himself at 
the foot of the couch, tells the patient to keep her knees as tight together 
as possible, whilst he forcibly abducts the thighs ; and again he tells her 
to try to keep the knees apart whilst he forcibly brings them together. 
The effect of this alternate action of her adductor and abductor muscles 
is to increase the vigour of the muscular structures within the pelvis. 
This is further favoured by stimulation of the lumbar muscles, and 
gymnastic exercises calculated to develop the patient's muscularity, but 
these are not essential to the cure of the prolapsus. Those who have 
succeeded in this " kinesitherapeutic practice," as it has been called, have 
expressed the conviction that it will lessen the frequency of surgical 
operations ; but it is admitted that the method is not quickly learnt, and 
that its application requires long fingers, a supple hand, muscular activity 
and dexterity, and inexhaustible patience. 

ii. Retention after replacement. — The reduction of the prolapsed uterus 
is usually easy of accomplishment. It is far otherwise with its retention 
in place. The attempt to fultil this indication may be made either 
by the application of some kind of support; or by the employment 
of some operative procedure. The former line of treatment is for the 
most part merely palliative ; the latter aims at a more radical cure. 

(a) Palliative measures. — Among the means we have been employing 
to reduce the inflammatory conditions in the pelvis an important place 
will have been given to the use of pledgets of cotton soaked in glycerine. 
For deobstruent purposes the glycerine will have been medicated with 
ichthyol ; where a more astringent action is desired an astringent like 
tannin will have taken the place of the ichthyol. These pledgets of 
cotton may so fill up the vaginal cavity as to have at the same time the 
effect of supports to keep the uterus in place. Or the vagina may be 
packed tensely with iodoform gauze or salicylated cotton wool ; when the 
packing has again the double function of keeping up the uterus and pro- 
moting absorption of inflammatory deposits. Such vaginal tampons 
require to be changed every two, three, or four days. Patients can wear 
a tampon of marine lint for a week without any discomfort ; but a woman 
cannot be expected to go on for any length of time using vaginal tampons 
that may require the assistance of the medical attendant for their proper 
application. Accordingly, when these have fulfilled their function in 
lessening the pelvic congestion, and have demonstrated that a foreign 
body can be retained in the vagina which prevents the recurrence of the 
prolapse, the practitioner has to consider what kind of vaginal pessary 
will be likely to keep the patient comfortable. Now the variety of 
vaginal pessaries is endless. There are differences in — 

(a) The material of vaginal pessaries. — They are sometimes made of 
metal. Of these the most practical are the rings made of some flexible 
material that allows of changes in their form to suit individual cases. 
Pessaries of wood were at one time in frequent use ; and they have been 
made also of ivory, bone, and of soft materials covered with some im- 
pervious substance. These have now been almost entirely replaced by 



DISPLACEMENTS OF THE UTERUS 407 

india-rubber, either in its soft state or in tbe hard state of vulcanite. 
The soft rubber pessaries have the advantage of easy application to 
a wide range of cases : the drawback to their continuous employment 
is their tendency to lose elasticity when they lie for a length of time in 
the vagina ; at the same time they absorb secretions and become the 
source of disagreeable discharges. The pessaries of vulcanite can be 
worn for long periods, without undergoing any change or becoming the 
source of any trouble, if care be taken to see that they are properly 
adapted. They can be modified in form by being placed for a minute in 
boiling water ; but they are apt to break when attempts are made thus 
to change their curves : hence it is necessary for the gjaisecologist to have 
a set of vulcanite pessaries of different size and outline always at hand. 
If he can procure pure gutta-percha he has at his command a material out 
of which he can fashion a pessary for any given case. In boiling water 
gutta-percha becomes so soft that a piece of the proper size can be rolled 
between the palms of the hands till it has the form of a smooth round 
ball ; and further manipulation can then mould it into the form of a disc 
and stem, of a hollow perforated disc, or of a simple ring or horse-collar, 
according to the requirements of the case. Patients have sometimes worn 
gutta-percha pessaries for years with comfort. But, as the material is 
somewhat porous, it is better for the practitioner, when he has found the 
form and size that suits his patient, to send the gutta-percha instrument 
to the manufacturer in order to have one of the same pattern modelled 
in vulcanite. The only material that can compete with vulcanite in 
lightness, smoothness, and freedom from irritation in the vagina is 
celluloid. 

(/?) Theshapeof vaginal pessaries. — Globularor egg-shaped pessaries, 
hollow and made of vulcanite, are very serviceable where the perineum 
has still some retentive power, and the patient suffers from a tendency to 
descent of the vaginal walls and the uterus ; especially in elderly women. 
In many cases the ring pessary gives satisfactory results. The soft 
india-rubber ring is easily introduced and adapted to the vaginal cavity. 
It should be carried up so as to lie in the vaginal roof, the posterior 
being higher than the anterior border, and should find its support on the 
upper surface of the plane of the levator ani. Where there is a marked 
degree of cystocele the ring should be filled with a perforated diaphragm 
which serves to retain the anterior vaginal wall better in position. The 
soft pessary, however, should not be left for prolonged wear ; but if the 
ring give comfort it should be replaced by one of vulcanite or celluloid. 
Instead of a simple ring, a pessary that is discoid or saucer-shaped will 
often retain the structures better in position. Such a pessary holds all 
the better if the posterior border be made thicker than the anterior; and 
it may be worn for many months without any discomfort. A series of 
perforations allows of the free escape of the menstrual discharge, and 
allows of the washing out of the vaginal cavity with the douche. Where 
the ring or the saucer-shaped pessary fails to keep in place, the herniation 
can sometimes be prevented b}^ making the patient wear a disc and stem 



4o8 SYSTEM OF GYNAECOLOGY 

pessary; the stem projecting from the lower surface of the disc lies 
between the labia. The disc may be circular, but is better elongated 
from side to side so as to keep the walls of the vagina extended trans- 
versely. The patient learns easily to introduce such a pessary as she lies 
on her back, by passing in first the one side through the vaginal orifice 
and then the other, as a button is passed edgewise through a buttonhole. 
She removes it from time to time when going to bed by laying hold of 
the stem with the finger and thumb of one hand, while the forefinger of 
the other hand lays hold of one edge of the disc and presses it out. She 
can thus secure the cleanliness of the instrument and, if need be, 
she can douche the vaginal cavity in the interval of removal. The 
Zwanck and other pessaries with hinges and screws are all unsatisfactory. 

When the ball, the ring, or the discoid pessary fail in consequence of 
extensive lacerations of the perineum, or relaxation in the muscular planes 
of the pelvis, the patient may still obtain some relief from her displace- 
ment by wearing an abdominal bandage in addition to the pessary. A 
perineal strap passing between the patient's thighs will keep the 
pessary in place ; or the pessary may be fixed to the bandage by a 
curved metallic rod, or by elastic bands. But as in the case of patients 
with an inguinal hernia where a truss does not give relief, the surgeon 
proposes to the patient an operation for the radical cure, so here, when 
there is a multiplicity of arrangements required for the relief of the 
pelvic hernia, the gynaecologist will suggest that it is better to have 
recourse to some operative procedure likely to effect a cure of her 
condition. 

(h) Operative measures. — There are four different directions in which 
he may proceed to effect his purpose of securing the uterus in its proper 
place, and he is guided in his choice partly by the primary fault which 
initiated the displacement, and partly by the changes which have ensued 
in the dislocated structures. He may seek (a), to lessen the pudendal 
aperture ; (/?), to narrow the vaginal canal ; (y), to diminish the size of the 
uterus ; (8), to tighten the uterine ligaments. In some cases a single 
operation suffices to remedy the mischief ; in others two or more of the 
operations must be carried out in the same individual, and usually he 
finds it best to perform them all at once rather than at intervals. 

(a) Operations on the pudendal aperture. — The frequency with which 
the dislocatory process follows relaxation or rupture of the perineum warns 
us that in a large proportion of cases an essentialelementin the radical cure 
will consist in the tightening of the pelvic floor and narrowing of the 
pudendal aperture. Where the orifice has become preternaturally wide 
without laceration of the perineum, the operation that constricts it is 
designated episiorraphy ; where a damaged perineum must be repaired the 
operation is d, perineorraphy. Various methods have been followed in the 
attempt to narrow the aperture and to strengthen the pelvic floor in one 
operation, by making a raw surface extending round the posterior half or 
two-thirds of the vulva, and bringing it together from the two sides with a 
series of sutures. The best results are obtained, without removal of any of 



DISPLACEMENTS OF THE UTERUS 409 

the mucous membrane, by splitting off the vulvo-vaginal mucous mem- 
brane from the subjacent tissue either with a knife or, more rapidly, with a 
pair of scissors. The anterior extremity of the incision on each side comes 
at least as far forward as the base of the nymphse, and the dissection of 
the mucous membrane proceeds through the whole extent of the perineum 
until the point is reached that corresponds to the junction of the middle 
and lower third of the vaginal canal ; there some areolar tissue only 
intervenes between the vagina and the rectum. Where the perineal 
damage has invaded the anal canal the recto- vaginal septum has to be 
split higher up ; and while the dissection is carried forward to the usual 
extent in the direction of the nymphse, in this case it must also be carried 
backwards around the anal gap beyond a dimple or depression which can 
usually be seen in the cicatricial tissue on each side, indicating the point 
of insertion of the ends of the sphincter ani which is torn across. Such 
dissection produces a raw surface of large extent, in the sides and depth 
of which the torn or relaxed musculo-fascial tissues are freely exposed. 
These may now be brought together by means of a continuous catgut 
suture, which is introduced at first in the centre of the vaginal flap and 
is carried backwards towards the anal margin from side to side in the 
depth of the wound. It then runs forward, laying hold of the sides 
of the wound in the middle of the raw surface ; and the next stage, 
which again runs backwards, brings the edge of the wound into close 
apposition. 

(/8) Operations on the vaginal walls. — When pessaries have been left 
so long unattended to in the vagina that they have produced ulcerative 
processes in the vaginal walls, their removal is sometimes followed by a 
cicatricial contraction of the canal which makes the patient independent 
of further aid. In such patients, however, the non-recurrence of the pro- 
lapse is not due simply to the narrowing of the hernial canal, but to the 
changes that have taken place also in the uterus and its ligaments ; for they 
are usually women who have passed the climacteric period with its atrophic 
processes, and the uterus has long been kept up in its normal place. The 
attempt to prevent prolapse by producing a cicatricial ring in women at an 
earlier age, and whilst the uterus is still subject to its menstrual changes, 
is not encouraging in its results. A circular ulcer has been made by means 
of the actual cautery high up in the vagina ; or a tape has been passed 
round underneath the mucous membrane and tied so tightly as to ulcer- 
ate its way out. The circular scar, however, that results is continuously 
strained by the heavy uterus, and, receiving no support from the relaxed 
tissues below, becomes distended in no long time ; the uterus thus sinks 
through, and the whole prolapse is reproduced. 

The most satisfactory results are obtained by the procedures that 
narrow the vagina, not in a circular, but in a longitudinal direction. Raw 
surfaces two inches in length and nearly as broad, made on corresponding 
portions in the middle of the anterior and posterior walls, have been 
brought together so as to produce a strong bridge which prevents pro- 
lapse ; or the anterior and posterior walls have been sewn together after 



4IO SYSTEM OF GYNECOLOGY 

the mucous membrane has been dissected off the sides of the canal. The 
procedure that is usually indicated has been called anterior or posterior 
Golporraphy or elytrorraphy, which signify a narrowing of the anterior or 
posterior wall of the vagina throughout their length. In some cases the 
posterior colporraphy constitutes part of the operation for perineal repair, 
some portion of the redundant mucous membrane on the back wall of the 
vagina being dissected off, and the wound closed by sutures running from 
side to side so as to narrow the cavity just above the perineum. Most 
frequently the indication is for an anterior colporraphy. The anterior 
vaginal wall was the first part to undergo displacement ; it gradually be- 
comes distended, thickened, and indurated; and whilst these changes may 
be modified by keeping the patient at rest, by the wearing of pessaries, 
or by narrowing of the vulvar orifice, they can only be effectually re- 
moved by a surgical operation. A circular portion of the mucous mem- 
brane may be dissected off the most prominent part of the wall, and 
the wound closed like the mouth of a purse by a suture that runs round 
the margin. Eaw surfaces about half an inch in breadth may be made 
towards the side of the wall, and brought together in the centre of the 
canal by means of silver sutures kept in place for three weeks. These 
raw surfaces are wider apart in the fornix and converge toward the 
urethra. Better still it is to make an elongated elliptical wound surface, 
the upper end of which begins close to the cervix uterus, widening as it 
goes down till in the middle the entire breadth of the wall is denuded of 
its mucosa, and narrowing again as it comes down toward the urethral 
orifice. A continuous catgut suture closes the wound in stages. Intro- 
duced at the urethral end, it narrows the raw surface as it is carried from 
side to side till it reaches the cervical end ; as it is carried down again 
towards the lower extremity it brings the sides of the wound together 
near the mucous membrane at the widest part ; and in its third stage, as 
it is again passed upward, it will bring together the mucous membrane 
at the margins. This operation narrows the anterior wall, constricts 
the vaginal canal throughout its length, and, when conjoined with the 
perineal repair which is likely to be required, gives the surest hope of a 
radical cure in the great run of cases of prolapsus uteri. 

(y) Operations on the uterus. — When the uterus itself is enlarged, 
whether primarily or secondarily, it becomes necessary to secure its dimi- 
nution by other than the ordinary antiphlogistic measures. This often 
occurs spontaneously to a remarkable degree during the time when the 
patient has to keep at rest after a perineorraphy or colporraphy ; and will 
all the more certainly and completely take place if these operations have 
been preceded by a curetting of the uterine cavity. If cervical hypertro- 
phy be present, amputation of the cervix, or of some portion of it, may 
form the leading indication. It may be that one or both of the lips or 
the entire infravaginal portion has to be removed, and when the patient 
has recovered from the effects of the operation the uterus will retain its 
place. In other instances the amputation must go further ; the inter- 
mediate portion must be dissected from the bladder so as to allow of its 



DISPLACEMENTS OF THE UTERUS 411 

removal. Extirpation of the entire uterus has sometimes been carried 
out. In most of these cases of prolapse vaginal hysterectomy will be 
easy of accomplishment; but this operation should be reserved for 
patients in whom there is some tendency to malignant degeneration. 

(8) Modifying the siqyj^orts of the uterus. — Two different procedures 
that were proposed in the first instance for the cure of backward displace- 
ments of the uterus, have been found serviceable in some cases of descent. 
These are the shortening of the round ligaments, suggested inde- 
pendently by Dr. Alexander of Liverpool and Dr. Adams of Glasgow, 
and usually named, after them, the Alexander- Adams operation ; and 
the fixation of the uterus to the abdominal parietes ; the so-called 
ventrofixation or hysteropexia. Various gynaecologists, both British and 
foreign, have reported favourable results from the employment of these 
procedures ; but the range of their applicability has not been clearty 
defined, and where they are undertaken the patient should be made 
aware of the attendant risks. 

B. Deviations in Position 

The uterus may be placed unusually far (i.) backwards, in a state of 
retro-position ; (ii.) forwards, in a state of antero-position ; or (iii.) to one 
or other side — right or left — lateri-position. These displacements of the 
uterus may be due, on the one hand, to tumours, inflammatory effusions, 
or hgemorrhagic extravasations pushing the organ out of its place ; or, on 
the other, to peritonitic adhesions or celliditic contractions pulling it in 
another direction. For example, a cellulitic swelling in the left broad 
ligament in its early acute stage will thrust the uterus towards the right 
side of the pelvis ; and if the inflammatory process end, as it sometimes 
does, in producing an atrophy of the ligament, the uterus Avill eventu- 
ally be dragged towards the left side. So a peritonitic effusion in the 
pouch of Douglas, in the acute stage, will press forward the uterus which, 
at a later period, if the parts become fixed by inflammatory adhesions, 
will be retro-posed. It is obvious that these malpositions of the uterus 
do not constitute the central phenomenon in any individual case ; still it 
is important to keep them in mind, because they are often found compli- 
cating some of the other displacements, and obscuring the diagnosis. 

They can usually be recognised by means of the bimanual examina- 
tion supplemented, if need be, by the use of the sound or volsella : their 
treatment falls under the treatment either of the causes that produce 
them, or of the displacements with which they co-exist. 

C. Deviations in Direction 

The uterus is subject to changes in the direction of the fundus, 
which may be displaced backwards, forwards, or to one or the other side. 
In either case there are two different conditions of the uterus itself to be 
observed : in one, the whole uterus is more or less rotated on its axis, the 



412 SYSTEM OF GYNECOLOGY 

body and the neck of the uterus form a straight line, the uterus is in a 
state of version, and we have retroversion, anteversion, or lateriversion. 
In the other case the body has mainly or alone undergone the change ; 
the body is bent on the neck, the uterus is in a state of flexion, and we 
have to do with retroflexion, anteflexion, or lateriflexion. The most 
important, from the practitioner's point of view, are the — 

I. Posterior Deviations. — These have sometimes been described 
under the convenient designation of retrorsions — a term which includes 
the cases where the entire uterus is displaced, the retroversions, and those 
where the body chiefly is displaced and bent on the cervix — the retro- 
flexions. In a simple retroversion the uterus has lost its tendency to fall 
forward to wardsthe symphysis pubis; the organ is to some degree stiffened 
so that the cavity of the body and canal of the cervix form a continuous 
line ; and it has become rotated on its axis so that the fundus remains 
permanently directed towards the sacrum, and the os, instead of looking 
backwards, is directed downwards or forwards according to the degree of 
version that has been established. The varying degrees of retroversion 
in individual cases should be estimated by noting whether the fundus 
is directed towards the promontory of the sacrum, or towards the first 
or a lower sacral vertebra. In a case of retroflexion the uterus has 
not only lost the normal anterior inclination, the body has also become 
permanently bent backwards. The os may still look backwards ; but, as 
in most cases of retroflexion there is some degree of retroversion present, 
the OS will come to change its direction also : thus in well-marked cases 
the fundus is found lying in the lowest part of the pouch of Douglas, 
and the os looking towards the lower margin of the pubic symphysis. 

Causes of Retrorsions. — Before studying causes on the part of the 
uterus itself, on the part of its ligaments, or on the part of the influences 
that tend to bring about these changes in the direction of the uterus, we 
may note that some cases are : — 

i. Congenital. — On post-mortem examination of infants and young 
children the uterus is sometimes found retroverted or retroflexed to a 
degree not to be accounted for by the dorsal decubitus of the body. In 
young married women the displacement may be present when there is 
no antecedent history to lead us to suppose that ordinary operative 
causes have been at work. I have seen two sisters, one married and 
the other single, suffering from retroflexion ; and the displacement reap- 
pearing in the two daughters of the married one. This congenital dis- 
placement is sometimes associated with elongation of the cervix or with 
shortening of the vagina, notably of the anterior wall ; but it may also 
occur without any concomitant deformity. 

ii. Changes in the uterus. — Whatever causes tend to produce (a) 
induration of the uterine tissues, and so to destroy its normal flexibility, 
tend to bring about a version of the organ. Subinvolution, chronic 
metritis, and tumours in the walls, which make the organ rigid and 
unable readily to accommodate itself to the distensions and evacuations of 
the neighbouring organs, especially of the bladder, render it liable to be 



DISPLACEMENTS OF THE UTERUS 413 

affected by the influences that press the fundus backwards, and so to 
suffer retroversion. Hence the frequency of this displacement in women 
who have given birtli to one or more children, and have subsequently 
remained sterile; for these chronic inflammatory changes in the uterus 
are very apt to arise in connection with puerperal processes, whether they 
begin in the placental site, as suggested by the elder Martin, or in other 
parts of the uterine parietes. When the anterior wall is chiefly affected 
a retroversion will result ; and this the more certainly the lower down in 
the wall the thickening is situated. (6) Of relaxation of uterine structure 
retroflexion is more likely to be the consequence. In cases of persistent 
retroflexion a notable atrophy of the posterior wall is usually found at 
the point of flexure which corresponds to the isthmus. In some instances 
this may be a consequence and not a cause of the flexion ; but in 
others loss of substance as well as loss of tone precede the displacement 
and favour its occurrence ; and in some patients, where both anterior and 
posterior walls are found thus thinned and relaxed at the isthmus, the 
uterus is liable at one time to be retroflexed and at another in a state of 
exaggerated anteflexion. 

iii. Changes in the ligaments. — It is in the loss of retentive power of 
some of its ligaments that we most frequently find the explanation of a 
retroversion. When (a) the utero-sacral ligaments are relaxed the cervix 
is liable to be carried too far forward, and then the fundus is likely to fall 
backwards ; (6) the retroversion is favoured when the round ligaments 
are relaxed, and fail in their function of keeping the fundus directed 
towards the abdominal wall: but whilst loss of tone in the utero-sacral 
and round ligaments is the most important element in the productiou of 
retroversion, we note (c) that the changes in these ligaments are frequently 
conjoined with relaxation of the broad ligaments and of the structures in 
the floor of the pelvis. We have seen, in dealing with prolapsus uteri, 
how influential are these conditions in leading to descents of the organ ; 
and we then note that descent is apt to be attended with retrover- 
sion and retroflexion. There is, however, another ligamentous change 
which may be chargeable with the production of a backward deviation of 
the uterus. This occurs when (c?) the utero-vesical ligaments are shortened 
as a result of chronic inflammation. The tense structures dragging the 
isthmus forwards, or keeping it somewhat immobile, prevent the uterus 
as a whole from making the excursions in various directions demanded by 
its relations to the neighbouring organs. The body remaining more 
mobile than the cervix, and retaining its normal flexibility, is apt to be 
turned back into the hollow of the sacrum, and a retroflexion is thus 
established. 

iv. Directly displacing influences. — Of the influences that tend im- 
mediately to produce retro-deviations of the uterus, we may note — (a) A 
strain or fall or other jar to the body which has sometimes preceded the 
appearance of symptoms associated with a retroversion or retroflexion of 
the uterus. In some such cases the pre-existing displacement may not 
have been recognised ; in others it is easily conceivable that a displace- 



414 SYSTEM OF GYNECOLOGY 

ment could be thus brought about, especially if at the time of the 
accident the fundus were lifted backwards by a distended bladder. (6) 
Habitual over-distension of the bladder, which will keep the fundus uteri 
directed to the promontory of the sacrum or beyond it : and a patient 
in whom the uterus is frequently in this situation will readily acquire a 
permanent retroflexion; and this all the more if the bowels have a 
tendency to constipation and require straining efforts for their evacuation. 
(c) A permanent backward fixation of the uterus which, in some cases, is 
a result of peritonitis leading to adhesions that bind the posterior surface 
of the uterus to the rectum and back wall of the pelvis. 

Complications. — When tumours of the uterus itself or of the neigh- 
bouring organs are associated with retroversion the displacement is of 
minor moment, and it usually disappears on removal of the growth. The 
most important complications depend on the tendency to inflammatory 
changes in the uterus. These inflammations are sometimes the cause, 
sometimes the consequence of the displacement ; in either case the dis- 
placement and inflammation tend to perpetuate and to aggravate each 
other. The inflammatory mischief may be found in the perimetrium, 
leading to fixation of the uterus in the pouch of Douglas ; or it may 
affect the mesometrium, producing a rigidity that especially perpetuates 
the retroversions. Most frequently the endometrium is affected ; and 
there is a chronic catarrhal process in the cavity of the uterus, which is 
likely to spread along the cervical canal and to pass out on the posterior 
lip in the form of an extensive granulating catarrhal patch. Among the 
most troublesome cases are those in which the retroversion is complicated 
with prolapse of the ovaries, because these glands are usually congested 
and tender when they become thus displaced, and may cause trouble in 
the adjustment of pessaries which, in other cases, would serve to retain 
the uterus in position and relieve the patient of her suffering. More- 
over, it has often been found on section that retroversions of the 
uterus have so far interfered with the function of the ureters as to 
have produced some degree of hydronephrosis. This rarely attracts 
attention during life ; but it is noteworthy that a considerable proportion 
of women, who are the subjects of movable kidney, have at the same 
time some uterine displacement, most frequently in the form of retrover- 
sion or retroflexion. 

The symptoms of retrorsions of the uterus are due partly to the 
displacement, and partly to the inflammatory changes that so frequently 
accompany or flow from it. They consist of — 

i. Disturbance of uterine functions. — This disturbance may affect either 
the menstrual or reproductive functions, and in many cases both of these 
functions are disordered. 

(a) Menstrual disorders. — While an amenorrhoeic patient may have 
a retroflexed uterus, as in some cases of superinvolution or in some cases 
of hydrometra or hsematometra, patients who are the subjects of retrover- 
sion or retroflexion usually suffer from increase of the menstrual flow ; in 
many instances, indeed, it is because of the menorrhagia that they seek 



DISPLACEMENTS OF THE UTERUS 415 

advice. The excessive flow, however, is symptomatic of the attendant 
endometritis rather than of the mere displacement- Sometimes dys- 
menorrhoea running throughout each menstrual period is a leading 
symptom ; and whilst in some cases this also finds its explanation in the 
inflammatory condition of the uterus, in others it is associated with the 
displacement; especially in cases where the uterus is so retroflexed as to 
have lost its erectile power, and where mechanical straightening of the 
organ relieves the menstrual pain. Intermenstrual discharges, again, 
presenting any of the characters of leucorrhoea, are most frequently due 
to catarrhal processes in the cervix or body of the uterus. 

(6) Eeproductive disorders. — If retroflexion be found in a patient 
who complains of dyspareunia, the explanation of the suffering will 
usually be found in some of the complications that are present — such as 
vaginismus or oophoritis — unless the displaced organ be itself the seat of 
an active inflammation. Sterility, on the other hand, is often the result 
of retroflexion, and thus a leading symptom of it. This may be the case 
in women who have never conceived. I have treated, for instance, two 
sisters in each of whom, after two or three years of childless marriage, 
the uterus was found retroflexed ; in both of them conception occurred 
after the uterus had been replaced with the sound and kept in place with 
a vaginal pessary. Still more constantly one finds the uterus turned 
back in the case of women who have given birth to one or more children 
and then cease to conceive. There are others, again, in whom conception 
occurs from time to time, but who bear no more children because, with a 
retro verted uterus, they become the subjects of habitual abortion. 

ii. Disturbance of neicfhbouring organs. — We have seen how much 
the positions of the uterus are modified by the changing relations of 
the adjacent viscera. When it loses its power of adaptation to these 
organs, and is persistently displaced, it may prove a source of irritation 
to them. Hence we have — 

(a) Interference with the rectum. — The patient sometimes suffers 
from mucous dejections and frequent desire for defsecation; more 
frequently there is obstruction to the easy escape of the intestinal 
contents, and the bowels are emptied with severe straining efforts. 

(6) Interference with the bladder. — The bladder may be unaffected ; 
but the patient who has a retroverted uterus is liable to suffer from 
frequent calls to micturition, or difliculty in evacuation of the bladder, 
especially if the uterus be at the same time enlarged. A patient who 
has not menstruated for two or three months and suffers from retention 
of urine is almost sure to have retroversion of the gravid uterus. 

(c) Interference with pelvic muscles and nerves. — Patients with re- 
troversion or retroflexion of the uterus sometimes seek advice because 
of pain referred to the pelvic cavity, to the sacrum, or to the lower 
extremities. In some the suffering is aggravated by any kind of 
exertion ; in others, where there is no pain, there is loss of power in the 
lower extremities, so that the patient appears paraplegic, and is only able 
to walk when the uterus has been righted and retained in its proper place. 



4i6 SYSTEM OF GYNECOLOGY 

(d) General constitutional disturbance. — Besides the more localised 
symptoms we may find the patients complaining of derangements of more 
distant organs, such as the reflex neuralgias, gastric distress, mammary 
irritation, and general depression that are so often associated with other 
forms of uterine trouble. 

The diagnosis, however, of a retroversion or retroflexion of the uterus 
cannot be founded merely on these functional symptoms. It can only be 
made out by direct physical examination. 

i. Abdominal palpation gives negative results. 

ii. Vaginal exploration. — The finger introduced into the vagina finds 
the OS looking downwards or even directly forward ; the anterior fornix 
empty ; and the posterior fornix occupied by a rounded resistant body, 
which, if a second finger be introduced, is felt to be continuous with the 
cervix and to move in concert with it. To acquire certainty as to the 
condition our great reliance is placed on — 

iii. Bimanual examination. — The fingers of the left hand applied to 
the hypogastric region press down the uterus and its adnexa so deeply into 
the pelvis that the index and medius of the right hand, by which the 
vaginal exploration is made, get more fully into contact with all the 
pelvic viscera. The forefinger being placed on the cervix uteri and 
the middle finger in the posterior fornix vaginae, the exact relations of the 
uterus can in most instances be distinctly defined. If it be retroverted 
the body is found running directly backwards whilst the os looks for- 
ward ; and if there be retroflexion the angle at which the body is bent 
on the cervix can be felt. In this manner, after a little experience, 
the practitioner succeeds in diagnosing the condition with the greatest 
certainty. Occasionally greater certainty is attained by introducing the 
medius into the rectum whilst the index explores by the vagina. 

iv. Use of the sound. — As gynaecologists first learned to appreciate the 
frequency of retroflexions of the uterus by the use of the sound before 
the bimanual method had been fully developed, so the young practitioner 
will often find it useful to satisfy himself of the direction of the body 
of the uterus by passing the sound in a case where his bimanual ex- 
ploration still leaves him in doubt. There are even cases where the 
most experienced gynaecologist is glad to avail himself of its services ; 
especially if the displacement be associated with tumours or with heemor- 
rhagic or inflammatory effusions. There are cases where the bimanual 
examination is impeded by the thickness, or painful because of the tender- 
ness of the abdominal walls ; the passage of the sound then speedily and 
painlessly clears up the diagnosis. 

V. Other aids to diagnosis. — The volsella may sometimes be used to 
pull upon the cervix, or the speculum may be introduced to determine 
the condition of the lips of the os uteri. For determination of the 
displacement in itself they are unnecessary. But to get the full benefit 
of bimanual examination it is often necessary to bring the patient under 
an anaesthetic. This becomes the more necessary where any tumours or 
adhesions are likely to interfere with the easy reposition of the organ ; 



DISPLACEMENTS OE THE UTERUS 417 

indeed, it may be dangerous to the patient to undertake the treatment 
of a case when these are overlooked. 

Prognosis. — " lis ne tuent pas, mais ils ne guerissent pas/' said 
Velpeau in one of the discussions in the French Academy of Medicine, 
when some of his confreres who were averse to the employment of 
pessaries argued that displacements of the uterus were not dangerous 
to life. Eetroversion or retroflexion of the uterus are assuredly not 
conditions likely to prove fatal, but they may be sources of life-long 
discomfort. The only conditions under which a patient with this dis- 
placement may get rid of her trouble would be (i) in the rare cases 
where, having escaped the danger of abortion, she has carried a child 
to the full term, and a normal involution of the uterus and its ligaments 
has been secured during the puerperium ; or (ii) Avhen the uterus under- 
goes such atrophy as sets in at the menopause. 

Treatment. — When a retroversion or retroflexion of the uterus is 
found in a patient who comes complaining of the symptoms described 
in the preceding paragraphs, the practitioner, before proceeding to deal 
with the displacement, must make sure that it is an uncomplicated 
case. In a very great proportion of instances the first indication he 
has to fulfil is — 

i. To comhat the complications. — Among these the inflammations in 
and around the uterus hold a foremost place. It is sometimes diflicult 
to determine Avhether the patient's distress be more due to the inflam- 
mation or to the displacement ; and it often enough happens that under 
antiphlogistic measures the walls of a rigidly retroverted uterus become 
softened, or the flaccid walls of a retroflexed uterus recover their toni- 
city and the organ rights itself. So perimetritic adhesions may become 
relaxed, cicatricial indurations of the utero-vesical ligaments may dis- 
appear, or tension be restored to utero-sacral ligaments that had lost 
their contractility ; spontaneous reposition of the displaced viscus may 
thus come about. When, after inflammatory conditions have been 
removed, the uterus retains its abnormal place, the inflammatory changes 
will all recur unless the uterus be replaced. There are many cases, 
moreover, where reposition of the uterus, without special antiphlogistic 
treatment, is followed by removal of the congestive and catarrhal 
symptoms. The next indication, accordingly, is to — 

ii. Replace the uterus. — Various methods have been adopted for 
securing the reposition of the retrorse uterus. 

(a) Posturing the patient. — When the patient is placed in the 
knee-elbow posture, and the perineum is pulled back, so as to allow 
the vagina to be filled with air, the vaginal roof, carrying with it the 
uterus, can be seen and felt to have fallen away downwards and for- 
wards. This posturing of the patient and manipulation of the parts 
has sometimes been used for the purpose of replacing the retroverted 
uterus. The manoeuvre has been specially commended under the idea 
that the patient by adopting it might succeed in freeing herself of the 
displacement. But whilst in a few cases of retroversion the uterus 

2e 



4iJ 



SYSTEM OF GYN.-F.COLOGY 



might by this means fall into its normal relations, in the great majority 
it will fail to do so. In them, and in all cases of retroflexion, when the 
patient is put in the genu-pectoral position and the perineum held back, 
it becomes necessary to pull the cervix downwards and outwards with 
a volsella grasping the anterior lip of the os, while the fundus is pushed 
into its proper place either through the posterior fornix vaginae or 
through the rectum. 




Fig. 118. — Eeposition of the retroverted uterus with the sound. 

(6) Bimanual reposition. — When a patient has been chloroformed 
for the purpose of careful diagnosis the best method of reposition is 
by the bimanual procedure. The fingers of the one hand are pressed 
through the abdominal walls towards the hollow of the sacrum ; and, 
while the middle finger of the other hand pushes the fundus upwards to 
bring it within reach of the abdominal fingers, the forefinger is used to 
push the cervix backwards until, under the concerted action of the two 
hands, the fundus is carried right forward to the symphysis pubis. 
Occasionally the fundus can be pushed up better by the medius inserted 
into the rectum. Even when the patient is not anaesthetised this 
manipulation can in many cases be carried out without much difficulty, 
especially where the abdominal walls are thin and flaccid. 



DISPLACEMENTS OF THE UTERUS 419 

(c) E-eposition with the sound. — When the practitioner is satisfied 
that he has to do with a uterus that is not bound down by adhesions, 
his simplest and speediest method of reposition is by means of tlie uterine 
sound. It can be effected with perfect safety if the operator be careful 
to move the handle through a wide area, as the point of the sound turns 
within the uterine cavity (see Fig. 118) ; and in this, as in other methods 
of reposition, it is necessary to carry the fundus uteri far forward till it 
comes to lie close to the symphysis. 




Fig. 119. — Hodge pessary in the vagina retaining the uterus in situ. 

In a few cases it suffices thus to replace the uterus, and to place a 
pledget of cotton and glycerine in the anterior fornix, when the organ 
maintains its proper set. Usually, however, it returns sooner or later to 
its abnormal position; and in many cases the retrorsion is reproduced 
almost immediately on the withdrawal of the sound or of the replacing 
fingers. The next indication to be fulfilled, therefore, is the — 

iii. Maintenance in place. — For this the application of a vaginal 
pessary in the form of a simple ring will sometimes suffice. Better still 
is the introduction of a Hodge pessary (Fig. 119), or Albert Smith's very 



420 SYSTEM OF GYNJECOLOGY 

widely serviceable modification of the Hodge pessary. In some cases 
this pessary is borne with more comfort if the upper bar be thickened, 
as in the pessaries of Gaillard Thomas and Prochownick. Where the 
utero-sacral ligaments are greatly relaxed, Schultze's figure-of-eight pes- 
sary, or his sleigh pessary, may become necessary. 

When we have to deal with retroflexions the vaginal pessary may be 
insufficient to retain the uterus in its place, and benefit is to be obtained 
by the cautious introduction of an intra-uterine stem. The Am ami intra- 
uterine vulcanite stem, fixed on the edge of a disc, does good service in 
keeping the uterus straight ; and when the anterior fornix is packed with 
iodoform gauze, or with pledgets of cotton or glycerine, the uterus is 
retained in position, and the walls recover their tone ; when three or four 
periods have passed the organ may keep its place, or be kept in it, by 
the use of a vaginal pessary. Instead of a rigid stem of vulcanite a soft 
india-rubber stem pessary, which is more easily retained, may be passed 
into the uterus. The intra-uterine pessary sometimes has to be supported 
and supplemented by the use of the vaginal pessary ; but care should 
be taken not to fix the two pessaries together in any such fashion as to 
interfere with the movements which the uterus must necessarily undergo 
in the changing relations of the pelvic viscera. 

Where patients continue to suffer from the effects of retroversion or 
retroflexion of the uterus unrelieved by mechanical appliances and anti- 
phlogistic remedies, we must consider whether by some operative 
interference a cure may be effected. It has been proposed to fix the 
cervix uteri to the back wall of the vagina, but experiments made in 
this direction have not been encouraging. Better results have been 
obtained from shortening of the round ligaments. Where the uterus 
has acquired adhesions that cannot be relaxed or severed by bimanual 
manipulations the operation of laparotomy, which will allow of the 
freeing of the uterus and its subsequent ventro-fixation, becomes jus- 
tifiable. Several operators have recently reported satisfactory results 
from a colpotomy which allows of the fundus uteri being reached through 
the anterior fornix and fixed anteriorly. The peritoneal cavity has 
even been opened into by the sacral method ; and after the uterus has 
been freed from adhesions the fundus has been carried forwards, and the 
pouch of Douglas obliterated so as to prevent relapse of the displacement. 
Such procedures, however, should be reserved for cases where the 
retrorsion of the uterus is complicated with some other condition, such 
as displacement or disease of the ovaries, which aggravates the patient's 
distress, and forbids the relief that can ordinarily be afforded by properly 
adjusted pessaries. Some time must elapse before their ultimate results 
and their relative values can be ascertained, and no conscientious 
practitioner would subject a patient to an operation extending to the 
peritoneal cavity without explaining to her the dangers to which she 
will be exposed. 

II. Anterior Deviations. — At one time many of the cases of dys- 
menorrhoea and sterility that came under observation were supposed to 



DISPLACEMENTS OF THE UTERUS 421 

be cases of anteversion, or more frequently of anteflexion of the uterus; 
and were maltreated as such. But since gynaecologists have recognised 
that, with the bladder empty, the uterus is normally in a position of com- 
bined anteversion and anteflexion, they have been less disposed to look 
to these antrorsions for an explanation of the sufferings of their patients. 
Some would even eliminate the anterior displacements altogether from the 
category of uterine disorders, and only admit the existence of a patho- 
logical anteversion or anteflexion when they can lay their finger on the 
condition that causes or keeps up the dislocation. But, however freely 
we admit that the sufferings associated with these displacements are trace- 
able to the causes that bring them about, or to the complications that 
attend them, there remains a residuum of cases in which the practitioner 
finds that he cannot effect a cure of his patient's condition without hav- 
ing regard to the displacement, and using means to correct it. As in the 
posterior deviations, so here the entire uterus may be rigid and rotated on 
its transverse axis, giving the condition of anteversion ; or the body may 
be bent more or less acutely on the cervix in the state of anteflexion. 

Causes and Complications of Antrorsions. — i. Congenital. — In early 
life the normal anteflexion of the uterus is very pronounced, and it is at 
the period of puberty that the body of the organ develops more decidedly, 
and tends to become more erect ; then the congestion of each menstrual 
epoch is attended with a distinct straightening of the utero-cervical canal. 
In some patients, however, such erection of the organ fails to occur ; 
and though for a time menstruation may go on painlessly, it is apt, in 
course of some months, to be attended with suffering. The uterus in 
such cases sometimes presents some other deformity, such as elongation 
of the cervix, or stenosis of the os ; or it is attached to a vagina with 
unusually short walls. 

ii. Changes in the uterus. — Inflammatory changes in the uterus may 
lead to an induration of the walls that gives a proclivity to anteversion, 
or to relaxation or atrophy of the tissues at the isthmus which will favour 
exaggeration of the normal anteflexion. But by far the greatest number 
of women who have pathological anteflexion of the uterus have also — 

iii. Changes in the ligaments. — It is in inflammatory contractions of 
the utero-sacral ligaments that we so frequently find the explanation of 
this distortion of the uterus. As they lay hold of the isthmus these 
ligaments, when they become shortened, drag the cervix uteri towards 
the hollow of the sacrum ; and, as the body of the uterus retains its mobil- 
ity, it becomes bent in an exaggerated degree by the jDressure of the 
superincumbent structures : the organ as a whole loses its power of 
adapting itself to the movements of the adjacent organs. The same 
effect is sometimes produced when adhesions have formed in the pouch 
of Douglas which fix the cervix to the rectum but leave the fundus free 
to become permanently anteflexed. 

iv. Directly displacing inffuences. — Whilst increased weight or relaxa- 
tion of texture of the uterus, and abnormal shortenings of its posterior liga- 
ments, favour the occurrence of the anterior deviations, they are directly 



422 SYSTEM OF GYNECOLOGY 

produced by pressure bearing on the posterior surface of the organ. The 
ordinary intra-abdominal pressure may of itself produce the result under 
favourable conditions ; but in some patients there is further pressure 
from the presence of tumours, or even from habitual constipation. In 
some very rare instances the uterus is fixed forward, as the result of 
inflammatory adhesions that have formed between the fundus and the 
bladder or anterior abdominal wall. 

The causes that bring about the displacement very commonly remain, 
to some extent, as complications of the mischief ; and they have to be 
carefully kept in view in the treatment of every case: moreover, as 
many of these patients become the subjects of salpingitis and oophoritis 
as well, the possibility of these complications being present must never 
be forgotten. 

The symptoms that chiefly attract attention here are dysmenorrhoea 
and sterility. The patients may also have leucorrhoea, or trouble with 
the bladder or bowels, or be the subjects of pelvic and other pains ; but, 
for the most part, they come under observation as young unmarried 
women suffering from dysmenorrhoea, or as young married women who 
have never conceived, and are perhaps also dysmenorrhoeic. The men- 
strual pain is often due to the chronic utero-sacral cellulitis or other 
conditions causing the displacement ; sometimes it is due to the stenosis 
that complicates it ; sometimes it is to be referred to the endometritis 
that may in one patient be the cause of the anteflexion, and in another 
the consequence of it. There are yet others where the flexion leads to 
suffering because of the obstacle to the easy outflow of the menstrual fluid 
from a uterus that has lost its erectile property. As regards the sterility, 
we note that, whilst we find retroversion in a large proportion of the 
women who have given birth to one or more children, and then have ac- 
quired sterility, a greater number of those who are absolutely sterile, and 
have never conceived at all, are the subjects of anteflexion of the uterus. 
As with the dysmenorrhoea, so the sterility may sometimes find its expla- 
nation in the concomitant conditions ; but, when these have all been com- 
bated, there remains a group of cases where the patient does not conceive 
until means are used to correct the displacement. 

The diagnosis is made by bimanual exploration, which enables us to 
make out the size, direction, and relations of the uterus. The posterior 
parametritis or perimetritis that may have been the prime factor in 
loringing about the anteflexion is very likely to have produced at the same 
time some degree of retroposition of the organ, so that an imperfect 
exploration may lead to the diagnosis of a retroversion. Even with the 
greatest care it is in some patients difficult to make out the exact position 
of the fundus, unless the abdominal walls are thin, or the muscles are 
relaxed under chloroform. The sound is often helpful in determining the 
direction of the fundus. To facilitate its introduction it may have to be 
bent pretty sharply towards the point; but the most important matter 
to attend to in employing it in these cases is to avoid force in passing 
it onwards. When the point meets with resistance at the flexure, the 



DISPLACEMENTS OF THE UTERUS 423 

handle should simply be pressed backwards towards the perineum, when 
the finger in the anterior fornix will feel the body of the uterus settle 
down over the end of the instrument, and the diagnosis is made sure. 

The treatment must have regard, in the first instance, to the various 
conditions that may be found causing or complicating the displacement. 
Until the hypertrophied uterus is reduced in size, its tense ligaments 
relaxed, and the inflammatory processes in and around it subdued by the 
use of douches, vaginal plugs, medicated pessaries and the like, it will be 
vain to attempt to relieve the patient's symptoms by mechanical meas- 
ures calculated to correct the uterine displacement. For some gynaecolo- 
gists the treatment of pathological anteflexion would simply resolve 
itself into the treatment of uterine or pelvic inflammations. But it is 
to be remembered that the resorption of inflammatory deposits may 
sometimes be favoured by the appliances that have, at the same time, 
the effect of improving the position of the uterus ; and if symptoms re- 
main unrelieved by other measures, there is a clear indication for their 
employment. It has been found time after time that an intra-uterine 
stem pessary has promoted the disappearance of the endometritis which 
attends anteflexion ; dysmenorrhoeic patients have menstruated without 
suffering; the uterus was thus kept straight, and women previously 
sterile have conceived with the stem in the uterus. It must be borne 
in mind that with any active inflammation in or around the uterus the 
employment of stem pessaries is a source of danger, whether in the 
posterior or in the anterior displacements. The instruments used should 
be carefully sterilised and applied with antiseptic precautions. When 
the intra-uterine stem is to be worn for some time it is usually necessary 
to introduce vaginal plugs below it, or to apply a vaginal pessary. In 
cases of ante version a vaginal ring or a figure-of-eight pessary is often 
of use in relieving some of the pressure symptoms. 

Operative measures of various kinds, such as the fixation of the cervix 
to the anterior wall of the vagina in cases of ante version, and opening the 
pouch of Douglas to allow of removal of wedge-shaped pieces from the 
back of the uterus in cases of anteflexion, have been proposed and carried 
out. But though the operators have given favourable reports of their 
cases, the operative treatment of the anterior displacements of the 
uterus does not offer much prospect of triumph for plastic surgery. 

III. Lateral Deviations. — Lateral deviations of the uterus are 
occasionally met with in practice ; there may be dextroversion or dextro- 
flexion when the uterus is turned or bent towards the right, or sinistro- 
version or sinistroflexion when the deviation is towards the left side of 
the pelvis. These variations are usually found, however, as subsidiary 
phenomena in association with inflammations, hsematomas, or other 
tumours ; or they may complicate the anterior or posterior displace- 
ments of the organ. Hence they are of relatively small clinical impor- 
tance ; they give rise to no distinctive symptoms ; and their diagnosis and 
treatment are to be conducted according to the principles applicable to 
the detection and treatment of the more common deviations. 

A. E,. Simpson. 



424 SYSTEM OF GYNECOLOGY 



REFERENCES 

1. Alexander. The Treatment of Backioard Displacements of the Uterus and of 
Prolapsus uteri. — 2. Amann. " Ueber die mechanische Beliandlung der Versionen und 
Flexionen des Uterus," Archiv fdr Gynaekologie, xii. 319. 1877. — 3. Aran. "Etudes 
anatomiques et anatomo-pathologiques sur la Statique de I'Uterus," Archives generales 
de medecine, i. 139 and 310. 1868.— 4. Atthill. "On Retroflexion of the Uterus," 
Dublin Quarteiiy Journal, xlvii. 39. 1869. — 5. Bandl. "Ueber die normale Lage 
und die normale Verhaltung des Uterus und die pathologisch-anatomischen Ursachen 
der Erscheinung Anteflexion," Archiv fur Gynaekologie, xxii. 6408. 1884. — 6. Bantock. 
On the Use and Abase of Pessaries. London, 1884. — 7. Bennet. " On Anteflexion of 
the Uterus considered as a normal anatomical Condition," Dublin Quarterly Journal, 
xxiv. 314. 1857. — 8. Bion. " Resultate der Ventrofixatio Uteri," Inaugural Disserta- 
tion. Bern, 1893. — 9. Braithwaite. "On a new Mode of treating certain Cases of 
Retroflexion of the Unimpregnated Uterus," Transactions of the Obstetrical Society of 
London, x\x. 122. 1877. — 10. Murdoch Cameron. " On Retroflexion of the Uterus," 
Glasgow Medical Journal. June 1877. — 11. Campbell. " Pneumatic Self-replacement 
in Dislocations of the Gravid and Non-gravid Uterus," Transactions of the American 
Gynaecological Society, i. 19S. 1877.-12. Duhrssen. " Ueber Vaginofixatio Uteri," 
Centralblatt fiir Gynaekologie, xvii. 681. 1893. — 13. Emmet. " A Study of the Causes 
and Treatment of Uterine Displacement," American Journal of Obstetrics, xx. 1040. 
1887. — 14. Fehling. "Ueber die neueren operativen Bestrebungen zur Heilung 
schwerer Vorfallen," Be?Hiner klinische Wochenschrift, No. 39. 1895. — 15. Flai- 
schlen. " Zur Ventrofixatio Uteri," Zeitschrift fiir GeburtshUlfe und Gynaekologie, 
XXX. 525. 1894. — 16. Graefe, M. "Ueber die Behandlung (ins besondere die opera- 
tive) der Ruckwartslagerung der Gebarmutter," Volkmann's Sammlung, No. 125. 
1895. — 17. Grail y-Hewitt. The Mechanical System of Uteri}ie Pathology. London, 
1878. — 18. Hart, Berry. The Structural Anatomy of the Female Pelvic Floor. Edin- 
burgh, 1881.-19. Hermann. "Contribution to the Anatomy of the Pelvic Floor." 
Transactions of the Obstetrical Society of London, xxxi. 263. 1889. — 20. Hildebrandt. 
" Ueber Retroflexion des Uterus," Volkmann's Sammlung, "No. 5. 1870. — 21. Huguier. 
Memoire sur les Allongements Hypertrophiques du Col de V Uterus. Paris, 1860. — 
22. KiJSTNER. " Die Behandlung complicirter Retroflexionen und Prolapse besonders 
durch ventrale Operationen," Volkmann's Sammlung, No. 9; 1890: and "Eine einfache 
Methode, unter schwierigen Verhaltnissen, den retroflectirten Uterus zu reponiren," 
Centralblatt fiir Gynaekologie, \\. '^33. 1882. — 23. Leopold. " Ueber die Annahung 
der retroflectirten aufgerichteten Uterus an der vorderen Bauchwand," Volkmann's 
Sammlung, ^0.332,. 1889. — 24. Mackenrodt. " Die operative Behandlung der Retro- 
flexio Uteri," Deutsche medicinische Wochenschrift, xviii. 491 ; 1892: and " Zur Technik 
der Vaginofixation," Centralblatt fiir Gynaekologie, xvn.^Qb. 1893.-25. Martin, A. 
" Ueber den Scheiden- und Gebarm utter- Vorf all," Volkmann's Sammlung, Nos. 183, 184 ; 
1880: and "Die Colpotomie 2,ntQv\ov," Monatsschrift fiir GeburtshUlfe und Gynaeko- 
logie, ii. 109; 1895: and "Ueber die Combination der Exstirpatio Uteri Vaginalis mit 
plastischen Operationen ira Becken," Berliner klinische Wochenschinft, xxviii. 1085. 
1891.-26. Martin, E. Die Neigungen und Beugungen der Gebarmutter nach vorn und 
hinten. Berlin, 1866. — 27. Mayer, C. " Ueber Anteversio Uteri und ihre Behandlung mit 
Hiilfe von Gxxmxmv'm^QXi," Monatsschrift fiir GeburtshUlfe, xxi. 416. 1863.-28. Napier, 
Leith. " On the Treatment of Uterine Prolapse," Transactions of the Obstetrical Society 
of Edinburgh, xn.'&l. 1887. — 29. Neugebauer. " Zur Warnungbeim Gebrauche von 
Scheidenpessarien," Archiv fiir Gynaekologie, xliii. 373. 1893.-30. Olshausen. 
" Ueber Ventrale Operation bei Prolapsus und Retroversio Uteri," Centralblatt fiir 
Gynaekologie, x. 698. 1886. — 31. Panas. " Recherches cliniques sur la Direction de 
rUterus chez la femme adulte," Archives generales de medecine, i. 274. 1869. — 
32. Prochownick. " Ueber Pessarien," Volkmann's Sammhing, No. 225. 1883. 
— 33. RouTH. "On the Use of Intra-Uterine Stems in Uterine Disease," Transac- 
tions of the Obstetrical Society of London, xv.2h2. 1873.-34. Sanger. " Ueber Peri- 
neorrhaphie durch Spaltung des Septum Recto-vaginale und Lappenbildung," Volk- 
rnxmn's Sammlung, No. 301. 1888. —35. Von Scanzoni. "Ueber die Abtragung der 
Vaginal portion als Mittel zur Heilung des Gebarmuttervorfalls," Bertrdge zur Geburt- 
skunde und Gynaekologie, iv. 329. 1860. — 36. Schroeder. " Ueber die fortlaufende 
Catgutnaht bei plastischen Operationen," Zeitschrift fiir GeburtshUlfe und Gynaekologie, 



MORBID CONDITIONS OF FEMALE GENITAL ORGANS 425 

xii. 213. 1886. — 37. Schucking. " Eine neue Methode der Eadicalheilung der Retro- 
rtexio Uteri," Centralblatt fiir Gynaekologie, x. 181; 1888: and " Bemerkungen ueber 
die Methode der Vaginalen Fixation bei Retrotiexio uud Prolapsus Uteri," Ibid. xiv. 
123. 1890. — 38. ScHULTZE. Die Pathologle und Therapie der Lageverander7.tngen der 
(Jehiirmiutter, Berlin. The Pathology and Treatment of Displacements of the Uterus, 
translated by J. J. and edited by A. V. Macan. London, 1888. — 39. Simpson, J. Y. 
'■ Proposals for the Improvement and Elucidation of Uterine Diagnosis by means of a 
Sound or Bougie passed into the Uterine Cavity," London and Edinburgh Monthly 
Journal of Medical Science, iii. 701; 1843: and "On the Frequency, Diagnosis, and 
Treatment of Retroflexion or Retroversion of the Unimpregnated Uterus," Dublin 
Quarterly Journal, v. 371. 1848. — 40. Sinclair. "Ventrofixation of the Uterus," 
Medical Ch?'onicle, April 1894. —41. Skene. "Injuries to the Pelvic Floor," iVeifl 
York Medical Journal, xli. 289, 317, 403, 457. 1885.— 42. Smith. "Ventrofixation 
and Alexander's Operation compared," American Journal of Obstetrics, xxxii. 264. 
1895. — 43. Van de Warker. "Normal Position and Movements of the Unimpreg- 
nated Uterus," American Journal of Obstetrics, xi. 314 and 528. 1878. — 44. Varnier. 
"Des Cystoceles vaginales, avec on sans chute de I'Uterus, compliquees de Calculs," 
Annales de Gynecologic, xxiv. 201, 289, 366. 1885.-45. Veit. " Klinische Unter- 
suchungen ueber den Vorfall der Scheide und der Gebarm utter," Zeitschrift fiir Geburts- 
hiilfe und Gynaekologie, u.l4:i. 1887. — 46. AVerth. " Ueber die Anzeigen zur opera- 
tiven Behandlung der Retrotlexio uteri." Separatausdrvck aus der Festschrift zur Feier 
des fiinfzigjahrigen Stifungsfestes der Gesellschaft fiir Geburtshiilfe und Gynaekologie 
zu Berlin. 1894. — 47. Von Winckel. Die Behandlung der Flexionen des Uterus mit 
intra-uterinen Elevatoren. Berlin, 1872. — 48. Winter. "Zur Technik der Ventro- 
lixatio Uteri," Centralblatt fiir Gynaekologie, xvii. 625. 1893. — 49. Ziegenspeck. 
"Ueber Thiire Brandt's Verfahren der Behandlung von Frauenleiden," Volkmann's 
Sammlung, Nos. 353, 354. 1890. 

A. E. S. 



THE MORBID CONDITIONS OF THE FEMALE GENITAL 
ORGANS RESULTING FROM PARTURITION 

(Lacerations, Fistulas, Morbid Involution) 

The two Kinds of Injury in Child-birth 

Many of the diseases to which women are liable arise from injury 
received in child-birth. 

Two kinds of injury may occur : (1) The tissues may be mechanically 
damaged ; (2) micro-organisms and poisons produced by them may get 
into the tissues. Either kind of injury may result in much after suffer- 
ing; often both injuries are combined. 

In the pages which follow I shall describe the mechanical injuries 
which may occur in child-birth, and the effects of them which may persist 
after child-birth is over. The diseases to which these injuries, by per- 
mitting the access of micro-organisms, may indirectly give rise, are 
described in other sections of this System. 

The mechanical injuries are of two kinds : (A) tearing, and (B) 



426 SYSTEM OF GYNAECOLOGY 

crusliing. I shall first describe tearing ; and I shall take first the part 
which is the first to be torn. 

Mechanical Injuries — A. Tearing. — I. The Cervix Uteri. — In. 
some few labours the os uteri, solely by stretching, expands to a size 
large enough to let the child pass. But in most cases, as the force 
which is dilating the os increases as the size of the os increases, this 
force shortly before delivery becomes very great, and the enlargement 
of the OS is finished, not by stretching, but by tearing. If the accoucheur 
add to the force by pulling with forceps before dilatation is complete, 
the tearing is generally greater than in deliveries left to nature. The 
tears, whether produced by unaided nature or by the forceps, are gener- 
ally lateral. They may involve only the vaginal portion, or they may 
extend up to the os internum (see Fig. 122), down into the vagina, and 
outwards into the cellular tissue. They are often multiple, running in 
a stellate fashion from the os uteri ; but if so, the lateral tears are usually 
the deepest. Big rents are said to be most frequent on the left side ; but 
the preponderance is not great. Bents, great or small, are so frequent 
that their presence is a valuable presumptive evidence of antecedent 
child-birth. 

As some persons think that these tears entail very important after- 
effects, the first practical question is whether anything can be done to 
prevent such effects ? 

Should tears of the cervix be sewn up at oricef — Some writers have 
advised accoucheurs to sew up all tears of the cervix at once. This is 
difficult and troublesome. Moreover, as Freund has pointed out, these 
tears are irregular, and in the condition of parts after delivery it is dif- 
ficult to follow them up. The accoucheur may think he has sewn up 
the whole of a tear when there remains a gap above or outside his line 
of suture which he has not perceived ; and his stitches, by preventing 
free exit of discharge from such a spot, may favour retention and de- 
composition of discharge, and thus produce blood poisoning. In sew- 
ing up a deep rent it is possible to include the ureter in the stitches. 
During the involution of the uterus these tears heal to a large extent ; 
I therefore agree with Freund, that the suture of lacerations of the 
cervix immediately after delivery is only desirable when required to 
stop bleeding. 

TJie results of cervical lacerations. — Each tear of the cervix is an open 
wound. If during lying-in the genital organs are kept clean, and the 
lochia flow away properly, the wounds heal. The opposite surfaces of the 
tear may unite, and then no trace of it remains : but they seldom do, 
and the wound usually heals by granulation. Epithelium on one side 
develops from the mucous membrane of the vaginal surface of the cervix, 
on the other side from that of the cervical canal, and a fibrous scar is 
formed where they meet. 

When the cervix surrounding the os externum has thus been made 
into two lips, with a gap between them, and the patient gets up, the 
intra-abdominal pressure drives the cervix uteri against the posterior 



INJURIES IN PARTURITION \zi 

vaginal wall. This pressure force's the lips of the cervix asunder, and 
eversion of the lower part of the cervical canal is the result. By this 
eversion mucous membrane, which should not be exposed to any friction 
or pressure, is exposed to friction and pressure against the vagina. The 
effects of such friction and pressure are not the same in every case. In 
some, the part of the cervical canal exposed by eversion undergoes 
changes which make it like that of the vaginal portion ; its columnar 
epithelium becomes changed into squamous, its rugse become less prom- 
inent and may be effaced, and its colour becomes the same pale bluish 
pink as that of the vaginal portion. There is no inflammation of the 
cervix ; its lips, although everted, are not thickened, and no symptoms 
arise. This change is more likely to happen if the involution of the 
uterus has gone on well. 

In other cases, and especially in those in which there is subinvolu- 
tion, the friction and pressure produce and keep up chronic inflamma- 
tion of the cervix. Its lips become not only everted, but swollen ; 
instead of their profile (on section) being conical, as in Fig. 120, it be- 
comes club-shaped, as in Fig. 121. Its surface often becomes the seat 
of the adenomatous growth known as " erosion " — which name was 






Fig. 120. — Profile on section of Fig. 121. — Profile on section of lacer- 

lacerated, but healthy, cervix ated and inflamed cervix uteri 

uteri (diagrammatic). (diagrammatic). 

applied to it before its histological structure was known. The growth, 
as its name implies, is one of gland tissue. The orifices of these newly 
formed glands often become blocked, the secretion is retained, and the 
gland becomes converted into a cyst containing a clear viscid fluid, a 
muco-purulent fluid, or pus. These cysts may remain after all other 
signs of adenomatous growth have disappeared. 

The symptoms and treatment of the inflammation of the cervix thus 
produced or kept up by the eversion resulting from laceration are de- 
scribed in the section on Inflammatory Diseases of the Uterus. 

II. The Vagina. — Considerable injuries to the vagina seldom occur 
during the spontaneous birth of a living child, or even when the delivery 
of such a child is skilfully helped with forceps ; slight abrasions and 
shallow fissures, however, can be found after most first labours, if looked 
for, in the lower third of the vagina. 

Conditions favouring injuries to the vagina. — But laceration of the 
vagina sometimes takes place even when the child is born without 
assistance. There are four conditions which make the vagina more than 
usually liable to be torn. These are (1) contraction of the vagina by 
fibrous tissue : either parametritic exudation which has become organised 



428 



SYSTEM OF GYNECOLOGY 



into fibrous tissue, or scar tissue left after operations for vaginal fistulse, 
rupture of the perineum, or the removal of vaginal cysts. (2) In the 




C^ 



Fig. 122. — (After Freund.) Lacerations of cervix uteri and vagina. From nature. (The anterior part 
of the vagina, part of the bladder and pubic bones, have been removed, and a probe and drainage 
tubes inserted in the lacerations.) 

older primiparae the tissues stretch badly, and are therefore more likely 
to be torn. (3) Laceration of the vagina has been observed in cases of 



INJURIES IK PARTURITION 429 

difficult labour with small pelves, and it lias been inferred that the tear- 
ing has happened because the vagina Tt^as small as well as the pelvis ; 
but in such cases there is more than usual compression of the vagina 
between the head and the pelvis; moreover instrumental delivery is 
more often needed : these circumstances are to my mind a better expla- 
nation of the frequency of laceration of the vagina than a hypothetical 
smallness of the canal. (4) In some pelves the normal bony promi- 
nences are more pronounced than usual ; among them the ischial spines. 
If this be the case, the vagina is especially liable to laceration where it 
is compressed between the foetal head and these bony points. Tearing 
of the vagina in natural labour is apt to occur when the pains are very 
strong and the head very large, so that the stretching of the vagina is 
great and comparatively sudden. 

Situation of vaginal tears. — The vagina is narrowest at its lower part, 
but it is here thicker and stronger on account of the muscles and fasciae 
inserted into it. The median raphe of the vagina is its thickest part. 
The posterior wall of the vagina is longer than the anterior, and is more 
stretched during labour ; for it forms the outside of the curve along which 
the foetal head has to pass. Hence those tears that depend on rigidity 
of the tissues, or on large size and sudden expulsion of the head, are most 
often on the posterior wall and on one side, the side being that to which 
the face was turned during its passage through the pelvis (Fig. 122). The 
position of lacerations due to scar tissue, or to pressure upon prominent 
bony points, depends upon the situation of those structural peculiarities. 

Effects of disiDlacement of the vagina. — When the os uteri is fully 
dilated, and is drawn up over the head, the upper part of the vagina is 
pulled up. As the head is driven down, it presses the mucous membrane 
down before it. In these two ways the mucous membrane may be moved 
on the submucous tissue; it may either be pulled u^^ or pushed down. 

By such displacement of the vagina before the advancing head, the 
vagina is stretched from above downwards ; and as tears by stretching are 
transverse to the line of greatest tension, tears running transversely to 
the long axis of the vagina and parallel to its orifice are thus produced. 
Tears of this kind are generally near the orifice : Duncan estimated their 
frequency in first labours at about 12 per cent. From this movement it 
follows that injuries of the vagina caused by pressure on bony points are 
not always exactly over these bony points, but sometimes above them, 
forming a sinus or pocket running downwards (Fig. 123). Another 
consequence is that in the displacement of the mucous membrane on 
the submucous tissue, vessels may be torn and blood effused in quantity 
varying from a few ecchymoses up to a quantity sufficient to form the 
swelling of the labium knovTi as thrombus, or hcematoma of the vulva. 

Effects of instrumental deliver!/. — In the ways above described the 
vagina may be torn during natural delivery. But lacerations are more 
often produced directly, either by instruments, or by sharp edges or 
points of bone. Such tears may be deep, and extend into the bladder, 
ureter, rectum, or peritoneum. As a rule they imply unskilful mid- 



430 



SYSTEM OF GYNECOLOGY 



wifery ; either badly applied instruments, or pulling wrongly directed. 
But as the vagina is sometimes torn in natural delivery, it is clear that 
in the cases in which this is likely to happen, delivery in the most skilful 
manner with the most perfect instruments, cannot prevent the accident. 
A medical man is not, therefore, necessarily deserving of censure because 
the vagina was torn during instrumental delivery. Injury to the vagina is 
not an inevitable accompaniment of forceps delivery, but it is more likely 
to happen, and to be extensive, if delivery is hastened by forceps than if 
it is left to nature. 




Fig. 123. — (After Freund.) Laceration of vag'ina forming a "pocket." A drainage tube has been 
placed in the " pocket." From nature. 



Holo forceps delivery produces lacerations. — Forceps delivery adds to 
the risk of vaginal laceration in five ways. 1. The blades of the forceps 
increase by their thickness the measurement of the mass traversing the 
vagina ; the vagina, therefore, is a little more stretched, though not much. 
2. The forceps is used to hasten delivery ; its use, therefore, generally 
implies that the vagina is less gradually stretched than when dilatation 
of the soft parts is left to the comparatively slow action of the natural 
forces. The rate of progress is an important factor in the production of 
vaginal lacerations. 3. Unless the forceps exactly follows every movement 
of the foetal head, its blades cannot always lie flat to the head ; if they 
do not, then one edge of each blade will be raised off the foetal head. 
Although this projecting edge is not sharp, yet the vagina, where it is 



INJURIES IN PARTURITION 431 

pressed against this edge, is very tense, and may be cut ; this is the 
main factor in the production of forceps lacerations. 4. Tlie curve of 
the forceps is of greater radius than that of the head ; hence the vaginal 
stretching is not only increased at the poles of the diameter of the foetal 
head at which the forceps blades lie, but is enforced over a larger surface. 
Moreover, as I have said, the head in forceps delivery is made to move 
on more quickly, and as the dilating agent advances down the vagina, 
that canal must either dilate or move on in front of it. From the in- 
creased volume and increased speed of the dilating body, it results that 
the displacement of the vaginal mucous membrane over the submucous 
tissues before the advancing mass, composed of the head in the grasp of 
the forceps, is more than that which is produced by the head alone. The 
bulging down of the vagina before the advancing forceps can be seen in 
any high forceps delivery. 5. When the head is delivered by artificial 
pulling the normal mechanism is interfered with ; for the accoucheur can- 
not so exactly acquaint himself with the relations of the head and the pel- 
vis as to pull in the precise direction and at the precise moment which 
will adapt the head to the pelvis in the most advantageous manner. 
There is often, therefore, a greater diameter of distension at a given place 
than in the normal process, and in this way the probability of vaginal 
laceration is increased. The advocates of the axis traction forceps claim 
that it lessens the risk of laceration of the vagina. With this instru- 
ment the lifting of the edge of the forceps blade off the head, and the 
interference with the natural mechanisms, are lessened ; but I doubt if 
they are done away with. The other modes in which forceps delivery 
favours laceration of the vagina remain the same whatever the instru- 
ment used. 

Results of vaginal laceration. — Tears of the vagina are important; 
firstly, because they may cause haemorrhage after deliver3^ The treat- 
ment of such bleeding is a part of practical midwifery, and does not come 
within the scope of this article. Secondly, they make the patient more 
liable to puerperal illness ; for every wound opens a gate for the direct 
entry of septic organisms. The presence of suppurating wounds in the 
vagina increases the amount of the lochial discharge, and as wounds of 
the vagina may form pockets (3), in which lochial discharge may 
be retained and decompose, any active microbes present in the pas- 
sages will multiply in them. These microbes may so change the re- 
tained discharge that it becomes a chemical poison which produces 
fever (saprsemia) ; or in successive generations they may acquire fresh 
power, and produce septicaemia, phlebitis, and pyaemia ; or again pelvic 
cellulitis. 

Tears of the vagina may extend beyond the mucous membrane, and 
injure the fasciae and muscles which form the pelvic floor. These 
structures may indeed be injured without laceration of the mucous 
membrane ; or tears of the mucous membrane may heal, but the injury 
to the surrounding parts be imperfectly repaired. These injuries to the 
muscles and fasciae will be next described. 



432 SYSTEM OF GYNECOLOGY 

III. Injuries to the Muscles and Fasciae of the Pelvic Floor. — The fact 
that prolapse of the uterus is commoner in women who have had children 
than in virgins shows that this condition is favoured by child-bearing. It 
is certainly not due to lacerations of the vaginal mucous membrane, or of 
the perineum ; for complete rupture of the perineum may exist unrepaired 
for years without prolapse. It is therefore a reasonable inference that 
child-bearing favours prolapse by causing injury to those structures in the 
pelvic floor which are the main supports of the uterus, namely, the pel- 
vic fascise and the levator ani muscle. But our knowledge of these 
injuries has not advanced beyond opinion. I know of no dissection 
made to show the existence of the precise extent of such tears. 

Schatz has described subcutaneous or rather submucous laceration of 
the m'uscles forming the pelvic floor (chiefly the levator ani) as occurring 
during labour. He inferred it by feeling, through the vagina, gaps 
between the muscular bundles, gaps which he assumed to be produced 
by the tearing through of other bundles which ought to have filled 
these spaces ; but he has not verified this opinion by dissection. I have 
felt gaps between the muscular bundles such as Schatz describes, but 
I have failed to trace a subsequent tendency to prolapse in the patients 
in whom I detected them. Skene has also described subcutaneous or 
submucous laceration of the pelvic floor during delivery (presumably 
independently, for he does not refer to Schatz's paper, which was 
published about a year previously). He describes not only rupture, but 
fatty degeneration, atrophy, and paralysis of the torn muscular fibres ; 
but he does not say that he has verified either the ruptures or the degen- 
eration by dissection. He also describes a change in the position of the 
anus as a result of injury to the pelvic floor ; but it does not appear 
from his paper that he has compared the state of the parts before child- 
bearing, in any particular case, with the state after it : without such a 
comparison it is not possible to be certain that what are described as 
changes due to injury in child-birth are changes at all. Kelly has 
described "relaxation" as "the most important of all injuries of the 
perineum and pelvic floor." His description of the injuries is based 
upon that of Schatz, but contains nothing to indicate that he has veri- 
fied them by dissection. He says that as a result of these injuries the 
anal cleft is no longer a sharp, deep furrow, but is flat and shallow ; and 
the anus is set farther back and more exposed. But without knowing 
in the individual cases what was the condition of the parts before child- 
birth, it is not possible to be sure that the peculiarities mentioned are 
really the result of injury. The depth of the anal cleft depends princi- 
pally on the fatness of the buttocks, and the distance of the anus from 
the coccyx and pubes respectively is different in different women. 

For the reasons given, I believe that the fascise and muscles of the 
pelvic floor are often injured in child-birth ; and that such injury is the 
main cause of uterine displacements, notwithstanding that the fact has 
not yet been demonstrated by the exhibition of specimens. These dis- 
placements are described elsewhere in this System. 



INJURIES IN PARTURITION 433 

IV. Rupture of the Perineum. — Lacerations of the vagina are found 
out only by those who look for them. Injuries to the pelvic floor are a 
matter of inference, although their existence is almost certain. E,upture 
of the perineum has been known as long as midwifery has been practised. 

Tears of the vaginal orifice. — As the foetal head emerges, its stress falls 
first upon the vaginal, and then upon the vulvar orifice ; the vaginal 
orifice is marked by the hymen ; the posterior part of the vulvar orifice, 
which is the part made tense, is the fourchette. The vaginal orifice is 
in the nullipara its narrowest part; consequently if any part of the 
vagina be torn, it is this. The vaginal orifice is always torn in first 
labours. Such tears are often multiple and stellate, radiating from the 
vaginal orifice ; but whatever other lacerations may take place there is 
always one in the mesial line. Tears are more numerous on the left than 
on the right side. If the child is small the tear may be limited to the 
vaginal orifice, and not involve the fourchette. 

Tears of the perineum. — Cases such as those just mentioned are the 
exception. In many first labours (according to Duncan in 60 per cent) 
the tear extends upwards through the mucous membrane of the vagina, 
backwards through the skin of the perineum, and through the tissues be- 
tween them. This is rupture of the perineum. If the tear does not extend 
through the sphincter ani it is called "incomplete rupture." During 
delivery the perineum is stretched both from side to side and from above 
downwards. The tension of its anterior edge is from side to side, and 
therefore rupture here occurs in a line perpendicular to that of greatest ten- 
sion ; that is, from before backwards. When the anterior edge is stretched 
till it can stretch no more it gives way, and the tear extends until by it the 
opening has been made large enough for the head to pass. The extent of 
thetear depends uponf our factors; these are, (i.)theelasticity of the tissues; 
that is, the power of the tissue elements so rearrange themselves so that 
the part may elongate. Tears of the perineum are especially met with 
in elderly primiparae, whose tissues are less elastic than those of the 
young : the difference dependent upon age is not great, but it exists. 
We know not what the structural peculiarities are which make one 
perineum more capable of stretching than another, (ii.) The length 
and situation of the perineum. The length of the perineum (5) in the 
nullipara varies from five-eighths of an inch to two inches. The situation 
of the fourchette varies from as much as two inches behind the lower 
border of the symphysis pubis, to close up to the symphysis. It is obvious 
that if the perineum be short and its anterior edge far back, less stretch- 
ing will be required to let the child pass, than if the perineum be long 
and its anterior edge far forward, (iii.) The amount of stretching 
required, or in other words the size of the child. The birth of large 
children is oftener accompanied with rupture of the perineum than the 
birth of small children. Of children of average size the head is the 
largest part, and therefore that which tears the perineum. But in 
children of excessive size the trunk is larger in proportion to the head 
than in those of average size ; therefore with very large children the 

2f 



434 SYSTEM OF GYNECOLOGY 

perineum is liable to be torn, or a small tear to be enlarged, during the 
passage of the shoulders, (iv.) The suddenness of the stretching. The 
more gradual the stretching of the perineum the less likely is rupture to 
occur. E-upture of the perineum is especially apt to happen in labours 
completed by very strong uterine action (such, for instance, as is provoked 
by ergot), in which case the child is propelled quickly through the genital 
canal ; the same occurs in labours assisted with forceps if the child be 
too rapidly pulled through the vulvar orifice. It is not, however, a 
necessary consequence of forceps delivery; for this can be so managed 
as to give the perineum time to stretch. In labour protracted by weak 
pains, but ended naturally, rupture of the perineum seldom occurs. 




Fig. 124. — (After Eibemont-Dessaignes and Lepag'e.) Central rupture of perineum. From nature. 

Central rupture of the perineum. — The common kind of rupture of the 
perineum is that which has been described above — a tear beginning at 
the tense anterior edge, and extending backwards. The tear generally 
begins in the middle line, but, owing to the vagina being thicker in the 
median raphe, an extensive tear seldom keeps the middle line. 

There are less common ways in which rupture occurs. One way is called 
central rupture (Fig. 124) : in this form the tear begins in the posterior wall 
of the vagina, above the orifice ; then as the head is forced on, it presses 
into the tear in the vagina, widens it, presses asunder the muscular and 
fibrous structures of the perineal body, bulges down the skin in the 
middle of the perineum, and finally tears it. The tear, thus begun in 
the middle of the perineum, may extend forwards to the f ourchette and 



INJURIES IN PARTURITION 435 

backwards to the anus — central ruptm-e thus becoming complete rupture. 
Such I believe to be the common mode of production of central rupture 
of the perineum. But a tear of the vagina and cellular tissue of the 
perineum may not involve the skin of the perineum ; the skin of the 
perineum may be centrally split without injury to the mucous membrane 
of the vagina ; and the cellular tissue of the perineum may be torn 
without tear of either vaginal mucous membrane or perineal skin. The 
formation of a central perforation may begin in any one of these ways, 
the order of tearing being not always the same. Children have been 
born through central rupture of the perineum without injury to either 
anus or fourchette (10) ; although I think (w^ith Madame Lachapelle 
and Matthews Duncan) that it is more common for delivery to take place 
through the vaginal orifice even in the presence of a central rupture. 

Rupture from above downwards. — There is a still rarer mode of rupt- 
ure of the perineum which I have once seen. The recto-vaginal septum 
was first torn through, and then this tear extended downwards through 
the perineum. After the head had been delivered the hand protruded 
through the anus, and then the shoulder came down, tearing the perineum 
from above do^\Ti wards. Such a rupture must, of course, always be com- 
plete. This mode of rupture has also been reported by Baudry. 

Healing of perineal rupture. — If left untreated, incomplete rupture 
of the perineum usually unites through part only of its extent, by the 
union of granulations on opposite sides ; so that the perineum remains 
shorter than it was before. Complete rupture of the perineum occasion- 
ally heals without treatment ; but this is an exceptional event. 

Results of rupture of perineum. — Complete rupture of the perineum 
deprives the patient of the power of retaining faeces in the rectum. If 
a few fibres of the sphincter ani remain intact, so that its power is not 
destroyed, but only weakened, the patient may be able to retain scybala, 
but unable to retain fluid faeces. 

Incomplete rupture of the perineum enlarges the vaginal orifice. 
The consciousness of being " more open" is sometimes disagreeable to the 
patient. If the patient suffer from descent of the uterus or vagina, for 
which the support of a pessary is desirable, the shortening of the perineum 
may make it difficult or impossible to get a vaginal pessary retained. 

Neither complete nor incomplete rupture of perineum can cause pro- 
lapse of the uterus. I have seen a patient whose perineum had been 
ruptured twenty years before, in her first and only confinement, who 
had suffered since from inability to retain her faeces, yet she had not 
the slightest prolapse. But in the way above described rupture of the 
perineum much affects the success of the mechanical treatment of the 
prolapse. Central rupture of the perineum may heal incompletely, 
leaving a fistulous channel between the vagina and the perineum. 
Madame Lachapelle thought such fistula to be its usual consequence. 
That such fistulae are seldom now seen is a gratifying illustration of 
the progress of obstetric surgery. 

Treatment. — There is only one treatment of rupture of the perineum, 



436 SYSTEM OF GYNECOLOGY 

and that is a plastic operation. The description of the operation is not 
within the scope of this article. 

I come now to describe the injuries produced by crushing. 

Mechanical Injuries — B. Crushing. — Vaginal Fistulas. — 

Vaginal fistulas are among the most distressing consequences of mis- 
managed labour. There are three ways in which such fistulse may 
be formed : (1) By tearing. The tears in the vagina which have been 
described in the foregoing pages may be so deep and extensive as to 
open the bladder or the rectum, and then, if healing be imperfect, a 
fistula is left. This is the usual way in which recto-vaginal fistula is 
formed, but it is a rare mode of production of vesical fistulae. (2) By 
perforation, that is, by a sharp instrument or point of bone being 
thrust through the vagina into the bladder or rectum. This is a rare 
mode of origin of fistulas of any kind. Fistulas formed either by 
tearing or perforation have this feature in common, that the symptoms 
they cause appear immediately after delivery. (3) By sloughing. 
Nineteen out of twenty vesical fistulas are produced in this way. 
When so produced, symptoms do not appear immediately after delivery, 
but are postponed till after the separation of the slough. The slough- 
ing comes of continuous compression of soft tissues between the foetal 
head and the pelvic bones: such compression takes place when the 
membranes have ruptured, the amniotic fluid has drained away, the 
uterus has passed into a state of tonic contraction, and there is such a 
disproportion between the foetal head and the pelvic brim or cavity 
that the head cannot enter the one or pass through the other. If the 
head cannot enter the brim, the uterine force is exerted in compressing 
the soft parts nipped between the head and the most prominent points 
of the pelvic brim. In the ordinary form of contracted pelvis the 
most prominent points are the sacral promontory and the pubic sym- 
physis ; the pressure effects are therefore greatest opposite those points. 
If the pressure be so great as to kill the nipped tissues, they slough. 
This sloughing is produced not by the magnitude of the pressure, but 
by its long continuance without intermission. The after-effects of the 
sloughing depend upon the situation of the damage. 

Crushing of tissues ojjjyosite sacral promoyitory. — The vaginal wall, or 
the cervix uteri, may slough where there has been compression between 
the head and the sacral promontory, and such sloughing may open the 
pouch of Douglas. If the parts are preserved from septic infection the 
slough is separated, and Douglas' pouch is closed by adhesive inflam.ma- 
tion. Such adhesions may alter the position of the uterus, and some 
physicians think that such changes in the position of the uterus produce 
ulterior harmful effects. Information upon this point will be found in 
the article upon '' Displacements of the Uterus." 

Crushing of tissues opposite the symphysis pyuhis. — Sloughing in this 
situation is more important than in any other, because here it destroys 
the integrity of the urinary passages. The tissues which suffer most 



INJURIES IN PARTURITION 



437 



are those nearest the head, that is, the posterior wall of the urinary 
canal ; and therefore the result of such sloughing is incontinence of 
urine. 

Situations of urinary fistulas. — The place at which the sloughing takes 
place depends upon the extent to which the os uteri had been dilated and 
pulled up over the head at the time pressure became continuous (Fig. 125). 
Sometimes, although very rarely, the membranes rupture early, and the os 
uteri dilates slowly, so that the amniotic fluid has drained off, and pressure 
has become continuous before the bladder has been pulled up out of the 
pelvis. In this case the slough may involve the cervix uteri and the 
ureter, a uretero-cervical fistula being formed. (These are often spoken 
of as '• uretero-uterine fistulas," but the sloughing affects the cervix, not 



Cervico-vesica] 



Vesico-vasinaL^ — 



Uretliro-vac;inaL-- 




'Recto-va;;inal. 



Fig. 125. —(After de Sinety.) Diagram showing different kinds of fistula. 

the body of the uterus.) One or both ureters may, in consequence of 
sloughing, come to open into the fistula. It must be admitted as possi- 
ble that the tissues killed by pressure may comprise the ureters, and not 
the bladder ; but the most probable explanation of such cases is that the 
slough involved cervix, ureters, and bladder wall ; and that, while the 
urine was flowing away through the cervix, the gap in the bladder 
healed by granulation. iS'o uretero-cervical fistula has yet been dissected 
after death. If there is a persistent hole in the bladder as well as the 
destruction of part of the ureters and cervix, the condition is called 
vesico-cervical (or incorrectly vesico-iiterine) fistula. The destruction of 
tissue may involve a large part of the cervix uteri and the vagina ; and 
this state is called vesico-cervico-vaginal (or vesico-utero-vaginal) fistula. 
Fistulas involving the cervix uteri are rare ; according to Neugebauer 
they form about 8 per cent of the vesical fistulse which follow delivery : 



438 



SYSTEM OF GYNECOLOGY 



fistulas involving the ureter are still rarer ; they are rare, because press- 
ure during delivery seldom becomes continuous until after the cervix 
uteri has been pulled up out of the pelvic cavity. When at this latter 
stage of the labour pressure becomes continuous, the bladder wall is 
killed at the part where it is in relation with the vagina, and a vesico- 
vaginal fistula is the injury which results. 




-A^ 



Fig. 126. — (After Martin.) Annular sloughing of cervix uteri. From nature. Upper surface. 

It is possible that during labour the relation of parts may alter, or be 
interfered with, so that after part of the cervix, ureters, and bladder have 
been so compressed as to kill the tissues, the cervix may be pulled up, 
and continuous pressure come to be exerted on the bladder ; thus two 
fistulas, a vesico-cervical and a vesico-vaginal, are formed. The more 
probable explanation of the co-existence of two fistulas is that the slough- 
ing at first produced one large gap, but that across this gap a bridge of 
tissue has subsequently united. Cervical fistulas according to Neuge- 
bauer are more common in multiparas than in primiparse. 

Annular sloughing. — In cases in which the pelvis is contracted in all 



INJURIES IN PARTURITION 



439 



its dimensions, or, being normal in shape and size, the child's head is too 
large, the head may enter the pelvic cavity and become impacted there; 
that is to say, stuck fast, unable either to advance or to recede. If this 
happen, a ring of soft tissue where the head is in contact Avith the pelvis 
will be crushed all round. If the impaction take place before the dilatation 
of the OS uteri is complete, the cervix uteri may have its vascular supply 
cut off by the crushing of a ring of tissue above it, and may consequently 
slough. This sloughing may affect only a ring of cervical tissue, and, if 




Fig. 127. — (After Martin.) Annular sloughing of cervix uteri. From nature. Lower surface. 

so limited, the ill effects do not outlast the puerperium (Figs. 126 and 127). 
But the killing of tissue by pressure may affect more than the cervix ; it 
may involve also the upper part of the vagina and the base of the bladder. 
When healing has taken place, so far as it may after separation of such 
a slough, the vagina is found converted into a short funnel ending in 
scar tissue bounding a hole not large enough to admit the finger. I have 
recorded a case in which such sloughing (5) took place in a woman who 
was not pregnant : in that case I was not able to find out its cause. 
The slough is preserved in the London Hospital Museum (Fig. 128) 



440 



SYSTEM OF GYNECOLOGY 



(2123). I have seen a case in which sloughing took place after delivery, 
and the resulting condition was exactly the same as in the case above 
referred to ; therefore, although the slough was not preserved, I do not 
doubt that the same parts were involved. 

Symptoms. — The symptom of a vesical fistula, wherever situated and 
of whatever size, is incontinence of urine ; that is, the patient's urine 
continually runs away through the vagina. The only exception to this 
is that when the fistula is small the pressure of the vaginal wall against 
it will sometimes temporarily close it while there is not much urine in 
the bladder, and the patient is recumbent. Hence these patients some- 
times say that they can retain the urine for a time while lying down. 
The presence of a fistula is suggested, and may almost be affirmed by 
the urinous smell of the patient's clothing, before its discovery on 




Os uteri externum 



Fig. 128. — Slough in one mass of cervix uteri, upper part of vagina, and base of bladder. From a speci- 
men in the London Hospital Museum. No. 2123, Natural size. (Drawn by Dr. J. H. Sequeira.) 

examination. Incontinence of urine is not the same thing as irritation 
of the bladder, that is, frequent micturition ; although in both the patient 
may describe her trouble as inability to retain urine. When there is 
merely irritation the patient can generally empty the bladder often 
enough to prevent her clothing from being more than occasionally wetted ; 
but when there is incontinence this is impossible, and unless special pro- 
vision be made the clothes become saturated. 

History. — When a fistula has been formed in the usual way — that is, 
by sloughing of the parts from pressure — there is no incontinence until 
the slough has at some part separated. Hence the history will be that 
the patient had a long labour, but no incontinence of urine till from five 
to ten days afterwards (which is the usual time for the separation of the 
slough), or even later ; and that then the urine began to run away in- 



INJURIES IN PARTURITION 441 

voluntarily. If the fistula was produced by tearing or by perforation 
the incontinence of urine will date from delivery. 

Diagnosis. — This can only be finally made by physical examination. 
Put the patient on her side, and expose the cervix and vagina with a 
duck-bill speculum ; if there be a vaginal fistula the opening will be seen. 
Vaginal fistulas are often large ; and then the mucous membrane of the 
opx^osite vesical wall often bulges through the fistula, forming a rugous 
swelling of deeper red and more velvety feel than the vaginal wall. 
Cervical fistulas are generally small; a cervical fistula big enough to 
admit the finger is exceptional. 

If Avhen the cervix and vagina are exposed a fistula cannot be seen, 
and yet there is no doubt that urine continually escapes by the vagina, 
put a catheter in the urethra and inject milk into the bladder. If there 
be a very small vaginal fistula the white, conspicuous jet of milk escaping 
through it will mark its place. If the fistula be cervical the milk will 
come back through the cervix uteri. If the fistula be uretero-cervical on 
one side, the history will be that the urine flows continually away by 
the vagina, while yet some urine is passed naturally ; and when milk is 
injected into the bladder none will flow into the vagina. A cervical 
fistula involving both ureters is characterised by the flow of all the urine 
through a vagina which, on examination by injection of milk, shows no 
passage from the bladder to the vagina. 

Usual concomitants. — With a fistulous opening into the bladder there 
is generally more or less severe cystitis, so that the urine is ammoniacal 
and ropy. Injur}^, severe enough to cause sloughing of the bladder 
wall, often leads to sloughing at other parts of the genital canal, and to 
pelvic inflammation ; hence there is often fixation of the parts by parametric 
exudation and by contraction of the vagina by scar tissue at other places. 
The irritation of the urine causes inflammation of the skin of the labia 
and thighs ; and the mucous membrane and skin are often encrusted with 
earthy salts. 

Relation to operative delivery. — When inquiry is made as to the labour 
after which a fistula has formed, it is found in most cases that some 
abnormal condition was present ; and in many that operative delivery 
was required. Complications are frequent in such labours, because the 
disproportion which leads to continuous pressure also leads to disturbance 
of the mechanism of labour. There is no special complication other than 
disproportion, which produces sloughing and fistula as its consequence. 
The public are apt to think that the fistula was produced by the operative 
delivery, and it is true that in a few case^ fistula is thus produced. In 
the great majority of cases, however, — those in which the fistula is pro- 
duced by sloughing, — the fault lay not in the interference with natural 
delivery, but in the undue postponement of operative delivery. It 
is hardly necessary to point out, however, that delay in giving aid is not 
always the fault of the medical attendant. 

Treatment. — The curative treatment of a urinary fistula is its closure 
by a plastic operation. The description of these operations is beyond 



442 SYSTEM OF GYNECOLOGY 

the scope of this article. [_Vide art. ^^ Plastic Gynaecological Opera- 
tions."] 

The palliative treatment consists in the constant use of some appliance 
to receive the urine. While the patient is about the choice lies between 
a urinal, and absorbent pads frequently changed. The latter is the least 
disagreeable. Wood wool is the best absorbent material. The pads 
must be thicker than is required for the menstrual discharge, and must 
be changed often. If the patient be so situated that she must go for 
hours without the opportunity of changing the pads, she must wear a 
urinal — an appliance which consists essentially of a trough to receive the 
urine, whence it is conducted by a narrow tube to a bag. There are 
practically only two kinds : one in which the trough is made rigid, so 
that it keeps its shape, though its pressure may be irksome ; the other 
(known as the French model) in which the trough is made of thin 
flexible india-rubber: the latter is the less uncomfortable. At night 
discomfort is reduced to a minimum if the patient sleep on what is known 
as a " fracture bed " (that is, one with an opening in the middle for a 
pan), and is provided with plenty of absorbent material. 

It is best to postpone operation until at least two months after 
delivery, and this for two reasons : firstly, the parts become less vascular 
and the tissues firmer after involution is complete, both of which changes 
are conducive to success in the operation ; secondly, a vesical fistula, either 
cervical or vaginal, may spontaneously close. This is more likely to 
happen in the case of a cervical fistula, because such fistulas are small ; 
but I have known a vaginal fistula, big enough to admit several fingers, 
to close completely without operation. 

Recto-vaginal fistula, that is, an opening between the rectum and the 
vagina, is seldom produced by sloughing; because at the pelvic brim, the 
place where the tissues are most often nipped and made to slough, the rec- 
tum is at the side of the sacral promontory, and therefore out of the way 
of pressure. Such a fistula is generally the result of incomplete union 
of a bad rupture of the perineum, — the lower part of the rent heals, the 
upper does not. These fistulas are seldom large. 

A recto-vaginal fistula permits the involuntary escape of faeces and 
flatus from the rectum into the vagina. They are curable by a plastic 
operation, and in no other way. 

Morbid Involution 

Subinvolution means that the involution of the uterus after delivery 
has not been complete. To give a proper account of this, it is necessary 
first to describe briefly the normal process of involution. 

The involution of the uterus. — On the day after delivery the uterus 
weighs from a pound and a half to two pounds and a half ; and its fundus 
reaches as high as the umbilicus. Its return during the lying-in period 
nearly to the dimensions it had before pregnancy, is called " the involu- 
tion of the uterus." Generally by the twelfth day after delivery the 



INJURIES IN PARTURITION 443 

fundus uteri is no longer above the pelvic brim. Two weeks after 
delivery the uterus weighs about half a pound ; and three weeks after 
delivery from, four to six ounces. Involution is in most cases complete at 
the end of two months, sometimes at the end of a month ; but sometimes 
it takes as long as three months. 

How involution is effected. — We have no exact knowledge of the changes 
which take place in the peritoneal covering of the uterus. It becomes 
smaller, and the wrinkles present in it after delivery are smoothed away; 
this is all we know. It is stated in most text-books that the muscular 
fibres of the pregnant uterus undergo fatty degeneration during the lying- 
in period and are thus removed, new ones being formed in their stead. 
The alleged fatty degeneration rests upon observations by Kolliker, 
supported by those of Luschka, Sanger, and Mayor ; but it has been 
denied by Eobin. The opinion that the old muscular fibres are destroyed 
and new ones developed, was originated by Kilian in 1849. His state- 
ments were based on very few observations : most of them were on the 
uteri of women who had died from disease, and were made after decom- 
position had begun ; moreover, at the time they were made histology was 
in its infancy. The subject has been more recently studied by Dr. T. 
A. Helme, with the advantage of modern histological methods. He 
observed the process in the rabbit, and examined many specimens im- 
mediately after death, and at all stages of the process of involution. His 
results far outweigh the few and imperfect observations quoted in support 
of the text-book account. Helme finds no fatty degeneration. There is 
atrophy, that is, diminution in volume of the muscular fibres. There is 
not, as in a pathological atrophy, degeneration of the muscular fibres and 
increase of connective tissue, but a shrinking of muscle and connective 
tissue alike — a physiological retrogression. The change is probably 
chemical, a sort of peptonisation which makes the contents of the muscle 
cells more soluble, so that they can pass into the lymph stream ; but there 
is no fatty change. The atrophy goes on simultaneously and equally at all 
parts of the uterus alike ; no groups of degenerated cells are found amidst 
healthy tissues. Helme has noticed two stages in the process : during 
the first thirty-six hours the muscular fibres, which at the end of 
pregnancy are remarkably translucent, become cloudy and rapidly 
diminish in volume ; then a more gradual shrinking follows. Helme 
finds no evidence of a destruction of old fibres, or of a formation of 
new ones. The only change seems to be that large fibres become 
small. Broers has investigated the subject in the same way as Helme, 
and finds fatty degeneration. Helme tells me he thinks that the 
granules which Broers takes for fat globules are not such : in support of 
his opinion he points out that Broers found them in blood corpuscles, 
a place where fat globules would hardly be expected, and in the uterus 
during labour. 

Observations are also discrepant as regards the changes in the 
connective tissue. Fatty degeneration, atrophy, development of new 
connective tissue, have each been described. Helme finds that the con- 



444 SYSTEM OF GYNECOLOGY 

nective tissue at first becomes granular, and then gradually diminislies 
and dissappears. 

During the last few days of pregnancy and the first few days of 
involution giant cells with many nuclei are to be seen : they are formed 
by the coalescence of single cells which are probably leucocytes. These 
giant cells are not seen after the sixth day of involution. Their function 
is probably to eat up the waste material lying about them — granules 
from connective tissue or matter in solution from muscle cells. 

Structural changes take place also in the vessels. At the beginning 
of involution the veins are compressed by the contraction of the muscular 
bundles between which they lie : some of them become pervious again ; 
in others, their endothelium comes to present a hyaline and granular 
appearance, and the vessel is gradually obliterated and disappears. In 
some of the veins there is a proliferation of the intima, so that the vessel 
wall becomes permanently thickened. In some of the arteries there is a 
hyaline and granular appearance of the coats : some become obliterated, 
but in the larger ores there is a true proliferative endarteritis, growth 
taking place both from the endothelium and from the sub-endothelial 
connective tissue. At the end of involution the connective tissue around 
the arteries is increased in quantity, the arterial muscular wall is greatly 
hypertrophied, and the inner wall considerably thickened. On section 
the arteries project beyond the surrounding surface, and present thick, 
yellowish white walls, more opaque than the tissues around. This 
state of the arteries was described by Sir J. Williams in 1882 (15). He 
holds that it affords " the strongest presumptive evidence of parity " 
that we possess. 

In an ideal case involution should go on till the uterus is reduced to 
the same size as it was before pregnancy ; this, however, seldom occurs. 
It is so common for involution to be not quite complete that in text-books 
of anatomy it is stated that the parous uterus is normally larger than 
the virgin uterus. When involution is thus incomplete the condition of 
the uterus is called "subinvolution." In a few cases the involution 
goes on to such a degree that the uterus becomes smaller than it was 
before pregnancy. This is called " superinvolution " or " puerperal 
atrophy of the uterus." 

Tlie morbid anatomy of subinvolution. — We know of no constant 
difference, except in size, between uteri which a few months after delivery 
still remain large, and those which have returned to the ordinary size 
of the unimpregnated uterus. General enlargement of the uterus with 
pelvic pain and other symptoms is known as "chronic metritis," and some 
writers have described subinvolution and chronic metritis as identical. 
General enlargement of the uterus persisting long after delivery was 
described by Klebs under the name of "diffuse hyperplasia of the 
uterine parenchyma." He says that in some cases hypertrophy of the 
muscular fibres is present ; in others, hypertrophy of the connective tissue 
bundles. The more the latter are developed the firmer the tissue. 
He says that this hypertrophy has been regarded as a result of chronic 



INJURIES IN PARTURITION 445 

mflammation, and that in many cases inflammatory changes in the mucous 
membrane are unquestionably present ; in many others, however, there is 
no clinical proof of inflammation having been present, the condition having 
developed itself without any symptoms \yid. sect, on Fibrous Hyperplasia 
in Prof. Adami's art. on "Inflammation " in the System of 3Iedicine, vol. i., 
and also Dr. Mott's art. in same volume]. Both inflammatory and non- 
inflammatory forms have in common the enlargement of the uterus and 
increase in its blood-supply. Klob described chronic enlargement of 
the uterus as being due to a diffuse growth of connective tissue. He said 
that the uterus is at first congested and turgid, the connective tissue 
being immature ; but that the longer the disease lasts the denser the 
fibrous tissue becomes, compressing and perhaps obliterating the vessels, 
and making the uterine tissue paler and harder. At the beginning of the 
process, according to Klob, the muscular fibres are hypertrophied ; but 
later they are lost in the hypertrophy of the connective tissue. The 
uterus when so enlarged has all its diameters increased, but especially the 
antero-posterior measurement of the uterine body. The cervix is thick- 
ened. The uterine cavity is longer and broader, but its anterior and pos- 
terior walls are still almost in contact. Klob holds that the pathological 
change is not a result of inflammation, but a growth of connective tissue. 
Klob does not say how far his conclusions are based on the writings of 
others, and how far on specimens examined by himself ; nor does he say 
how many specimens he has examined, or from what women obtained. 
Without some knowledge of the age, the time intervening since the last 
pregnancy, the cause of death, and the associated morbid conditions in 
the pelvis, it is impossible to decide how far the changes described by 
Klob are such as naturally occur in healthy women as they grow older, 
or how far they are morbid. 

The causes of subinvolution} — For perfect involution of the uterus 
to take place, it is necessary that during the lying-in period the patient 
should be healthy and the uterus contracted. The contractions of the 
uterus, by intermittently compressing the vessels, mechanically help 
the circulation both of blood and lymph through the organ. When the 
uterine contractions are imperfect, the more languid movement of the 
blood helps to make involution slow and incomplete. Therefore, after 
post-partum haemorrhage — an accident which implies imperfect uterine 
contraction — subinvolution is apt to appear. Uterine contraction is es- 
pecially imperfect when a bit of placenta or membrane is retained. The 
presence of what (in the lying-in period) is a foreign body in the uterus, 
not only interferes with uterine contractility, but mechanically prevents 
the shrinking of the organ. When fever arises all the bodily functions 
are badly performed, and the natural metabolism is altered ; the uterus, 
like other tissues, then suffers, and its involution is retarded. This effect 
is especially marked when the cause of the fever is inflammation in the 
pelvis ; for then the uterus not only suffers, in common with the rest of the 

1 For an analysis of what has been done on this subject and original observations, see 
References (16) and (11). 



446 SYSTEM OF GYNAECOLOGY 

body, from the febrile disturbance of nutrition, but the local inflamma- 
tory disturbance affects its own circulation. Hence the most marked 
cases of subinvolution are those associated with pelvic inflammation. 
Again, when women have many children involution does not go on so 
fast, or take place so perfectly, as after their earlier labours. 

Subinvolution has been attributed to certain other causes which 
must therefore be mentioned : — (a) " General debility " : this is so 
vague a term that it may include almost anything, and its effects can 
neither be proved nor disproved. (6) Parturition late in life : the effect of 
multiparity has been mentioned, and women who have had many children 
are generally elderly ; but apart from multiparity, there is no evidence 
that the completeness of involution at all depends upon the patient's age. 
(c) Premature delivery : there is no evidence that after premature labours 
free from complication subinvolution is more frequent than after labour at 
term. Premature labour, however, is often induced for or by conditions 
— such as placenta praevia or constitutional disease — which lead to fever, 
or to imperfect contraction of the uterus ; for these reasons, and not be- 
cause delivery was premature, subinvolution may be more frequent after 
premature deliveries. (cZ) Laceration of the perineum : when there is a 
large wound of the genital passage the patient is more likely to become 
febrile than when the mucous membrane is intact ; for this reason sub- 
involution is more frequent when the perineum is badly torn than when 
it is not torn ; but the event is due to the fever, not to the rent in the 
perineum, (e) Lactation : some authors have stated that nursing favours 
involution, others that it hinders it ; no facts have been brought forward 
in support of either assertion; nor do we know the effect of lactation on 
involution. (/) Lacerations of the cervix uteri : these have no influence 
on involution. They are so high up that in a well-managed confinement 
pathogenetic microbes do not get access to them, and thus do not get the 
opportunity of causing fever, (cj) Plural pregnancy : as the uterus is 
here bigger than usual, involution may be slower ; but I know of no proof 
that it is so. (/i) Oilier alleged causes : phthisis, diabetes, Bright's disease, 
syphilis, chronic suppuration, pneumonia, bronchitis, emphysema, heart 
disease, rheumatism, mental disturbance, chorea, eclampsia, bad sanita- 
tion, retroversion of the uterus, have all been said to hinder involution ; 
but I have not found a particle of evidence to prove this effect of any 
one of them. They may or they may not cause subinvolution ; we have 
no knowledge on the subject. 

Effects of subinvolution. — Subinvolution in itself produces no disturb- 
ance of health. The uterus is often found large, but otherwise normal, 
in women who have had many children, and are quite well, but in whom 
examination was made because some disease was suspected. 

A tissue that is in any way degenerated is more vulnerable under 
adverse influences than one which is healthy. Emphysematous lungs are 
more liable to bronchitis than healthy ones. A woman who has often 
suffered from the oedema common in pregnancy, is more likely to get 
her feet swollen from fatigue than one whose feet have never been 



INJURIES IN PARTURITION 447 

cedematous. A uterus not well involuted is more liable to disturbances 
of its circulation, and to the morbid changes resulting therefrom, than a 
healthy uterus. The diseases to which subinvolution makes the patient 
more liable than she was before are described in other parts of this 
System. 

Subinvolution of the vagina. — During pregnancy the vagina develops 
as well as the uterus ; its vessels increase in number and size, it becomes 
larger, and its wall is thicker and softer. These changes obviously fit it 
for dilatation during child-birth. After delivery it undergoes involution ; 
it becomes less vascular, its capacity less, its mucous membrane firmer 
and thinner. So far as I know the minute anatomy of these changes has 
not yet been studied. In women who have had many children the in- 
volution of the vagina is often incomplete ; the canal remains larger, its 
mucous membrane thicker, its rugae larger. This subinvolution renders 
it more liable to catarrh, and women who have had children, especially 
those in whom the vagina is large and relaxed, are, therefore, more sub- 
ject to leucorrhoea than virgins. 

Treatment of suhinvolution. A. Preventive. — In the management 
of child-birth subinvolution is to be prevented (a) by taking care that no 
part of the placenta or the membranes is left behind in the uterus ; (6) by 
the daily administration of ergot for three or four weeks after delivery. 
This drug has no effect upon normal involution; if, therefore, it is cer- 
tain that everything is taking a normal course, the drug is unnecessary. 
But when any adverse condition prevents proper contraction of the 
uterus, ergot will hasten involution by making the uterus contract.' 
(c) By not allowing the patient to get about too soon, (d) I think, 
though I cannot adduce evidence in support of my opinion, that the 
use of astringent antiseptic douches during the lying-in period promotes 
involution of the vagina. 

B. Curative. — When the puerperal state is over, and involution still 
incomplete, no treatment will make the uterus get smaller. One event, 
and one only, will alter the state of the uterus ; that is, another preg- 
nancy. If the patient become pregnant, the uterus in the succeeding 
puerperium, if no contrary cause again hinder involution, may fall quite 
to its natural size, or even below it. 

Superinvolution of the Uterus. — What is superinvolution ? The word 
means that the uterine involution does not stop at the restoration of the 
uterus to its former size, but goes beyond this point, and leads to per- 
manent diminution of the size of the organ and arrest of its functional 
activity. The ill-formed word '*' superinvolution " was introduced by Sir 
James Simpson ; but the disease had been previously described under the 

1 In a paper by Dr. C. Owen Fowler and the author {Ohst. Trans., vol. xxx.), evidence 
!s published that in a series of unseleeted cases in which ergot was given, involution was 
less often delayed than in a series in which ergot was not given. The late Dr. Blanc, of 
Lyons, about the same time published a paper (see Lancet, 1892 v. 2. p. 1160), in which 
he compared two sets of cases, one with and one without ergot, and found that there was 
no difference in the rate of involution. But Dr. Blanc excluded all abnormal cases from 
his observations : his results are therefore in harmony with the view stated in the text. 



448 SYSTEM OF GYNECOLOGY 

better name by which it is still known in Germany, namely, '^ puerperal 
atrophy of the uterus." This term at once denotes its nature and its 
pathological alliance with atrophy of the uterus occurring in other 
circumstances. 

Morbid anatomy. — German writers speak of " excentric " and " con- 
centric " atrophy. Excentric atrophy means that the cavity of the 
uterus retains its natural dimensions, but that the wall of the organ is 
thinned, so that its external measurements are smaller. Concentric 
atrophy means that besides the wasting ot its wall, the uterine cavity 
is diminished in length and breadth. It is reasonably believed that 
excentric atrophy is an early stage of concentric atrophy. It is easy to 
recognize concentric atrophy ; but in the case of excentric atrophy it is 
difficult to say what degree of thinning of the uterine wall should be 
regarded as pathological, and very difficult to be certain of the existence 
of slight thinning. Hence statements about uterine atrophy, based on 
the supposition of excentric atrophy, are to receive only a provisional 
acceptation. It is said by German authors that some excentric atrophy 
takes place naturally during lactation ; and that after weaning the uterus 
returns to its normal thickness. It is difficult to be sure of this, for we 
have no means, in the living subject, of measuring the thickness of the 
uterine wall ; the fact of thinning rests only upon the impression of 
slightly diminished size gained by bimanual examination. Judging as 
well as I can in this imperfect way, I am disposed to think that the 
German observers are correct. In superin volution this normal atrophy 
of lactation goes on to a higher degree, and is permanent. 

When atrophy has advanced to the degree denoted by the word 
" superinvolution," the uterus is smaller in all its dimensions, and its 
wall is thinner ; its mucous membrane is either absent or very thin; 
its muscular tissue is thinned, the fibres are closely packed, and among 
its fibres thrombosed and obliterated vessels are to be seen. 

Etiology. — Certain puerperal diseases are followed by atrophy of 
the uterus. These are {a) any puerperal illness leading to cachexia, 
that is, to wasting and anaemia ; (h) suppuration of the ovaries leading 
to their destruction ; (c) pelvic cellulitis leading to a fibrous induration 
which, constricting the vessels, cuts off part of the uterine blood-supply ; 
(d) inflammation of such severity as to lead to sloughing of the inner 
part of the uterine wall — the so-called " endometritis dissecans." 
These diseases are rare, and recovery from them is rarer still. Puer- 
peral atrophy of the uterus is also an unusual disease. Hence the 
relation between these rare conditions is supported by a very few obser- 
vations. We know not what are the morbid changes in the ovaries, if 
any, upon which superinvolution depends. 

There are also diseases which may lead to amenorrhoea and atrophy 
of the uterus, apart from the puerperal state; it seems a reasonable 
inference, therefore, that if they occurred in pregnancy they would lead 
to atrophy of the uterus during the puerperium : but their influence in 
this way is but a probability, not a fact verified by observation. Among 



INJURIES IN PARTURITION 449 

them are phthisis, diabetes, Addison's disease, Graves' disease, myxoe- 
dema, insanity, emotional shock, paraplegia. 

The foregoing are possible causes. The disease is so rare that no 
series of cases large enough to place the ordinary causation of super- 
involution beyond dispute has yet been published. It is certain that 
superinvolution sometimes occurs in women in whom not one of the 
causes assigned for it (and enumerated above) has been present, and in 
whom examination reveals no other departure from the normal than that 
the uterus has undergone atrophy. 

Symptoms. — The only invariable symptom is amenorrhoea. Sterility 
is probably a consequence, but as the essential condition for fertility in 
the female is not the state of the uterus, but the production of healthy 
ova (as shown by the occurrence of pregnancy in a rudimentary uterine 
cornu), it cannot be asserted that superinvolution directly or necessarily 
causes sterility. Superinvolution probably, indeed, depends on ovarian 
atrophy ; but, as I have stated above, no morbid changes in the ovaries 
associated with superinvolution have yet been demonstrated. 

As the climacteric is really produced by superinvolution, the changes 
and symptoms usual at the climacteric gradually supervene. The breasts 
waste, and the patients complain of the chills, flushes, and sweats which 
usually trouble women at the menopause. The only other symptoms 
that I have seen associated with superinvolution are frequent headaches 
and leucorrhoea. Sir James Simpson says that superinvolution is 
associated with "constitutional ill health," "general debility," "depres- 
sion and impaired activity of mind." This is no doubt true, but it is 
difficult to disentangle cause and effect, and to be sure whether super- 
involution is the cause of ill health, or the ill health the cause of the 
superinvolution. In my judgment the latter view is the true one; I 
do not think that any symptoms belong to superinvolution except 
amenorrhoea, sterility, and the usual climacteric disturbances. 

Diagnosis of superinvolution of the uterus. — The diagnosis is suggested 
by the history, which is that of amenorrhoea dating from the birth of a 
child and continuing, although the patient has long ceased to suckle. It 
is made certain by finding out by physical examination the smallness of 
the uterus. This is done in three ways : — (a) By passing the sound. 
In this way the length of the uterine cavity can be accurately measured. 
A fallacy attends it, namely, that the sound may not have passed the 
whole length of the canal : therefore it needs to be supplemented by 
methods of determining the size as well as the length of the uterus. Of 
these the best is (6) bimanual examination, which means grasping the 
uterus between a finger in the vagina and a hand on the abdomen. 
Thus its size can be well estimated. If this cannot be done — either 
because from nervousness the patient keeps the abdominal walls very 
hard, or because she is very fat — then use method (c). Seize the cervix 
with a hook or volsella (the volsella gives the securer hold, but hurts the 
patient more), and pull it down towards the vulva. Then insert a finger 
into the rectum, and you will feel the whole length and breadth of the 

2g 



450 SYSTEM OF GYNECOLOGY 

posterior surface of the uterus. The smallness of the uterus thus ascer- 
tained establishes the diagnosis of puerperal atrophy. 

Treatment of superinvolution. — The only method of treatment which 
is unquestionably beneficial is the cure, if possible, of any condition of 
ill health which may be the cause of the uterine atrophy. The modes 
of treating the different causes of ansemia and wasting are described in 
the medical sections of this system. 

If the patient be florid, and the time at which menstruation should 
occur is marked by uncomfortable sensations, these symptoms may be 
relieved, and the uterus stimulated by the application of leeches to the 
cervix uteri. Cases of this kind are rare. 

Electricity has been recommended. The only kind of electricity 
likely to be effective is the passage of a current through the organ 
between an electrode applied to the uterus, and one on the abdominal 
wall ; I know of no evidence, however, that such treatment has proved 
useful. 

Stem pessaries, whether of glass, metal, or vulcanite, have been used. 
Sir James Simpson recommended a " galvanic stem," that is, an intra- 
uterine pessary made half of zinc and half of copper, the two halves 
lying side by side. When this is put into the uterus, the secretions of the 
part set up galvanic action between the zinc and the copper, and chloride 
of zinc is formed, which, being a caustic, inflames the mucous membrane 
with which it comes in contact. This is an injurious action. I know of 
no evidence that the galvanic stem does any good. But any intra-uterine 
stem, however unirritating the material, may produce peritonitis ; and 
I know of no evidence that such stems will make a uterus which has 
undergone superinvolution again develop itself. If intra-uterine stems 
of any kind are to be employed it should only be after explanation to 
the patient that the instrument is not likely to do good, and involves 
some risk to life. If the patient be rightly informed of the small pros- 
pect of benefit from local treatment, the dangers involved in it, and the 
unimportance of the effect of superinvolution upon health and duration 
of life, she will generally prefer to let it alone. 

It is to my mind very doubtful whether any treatment will make a 
uterus, which has fallen into atrophy, again develop itself. In most cases 
in which the uterus is small because it never has developed treatment is 
a failure ; and the jjrospect when the uterus has normally developed, has 
been functionally active, and then has wasted prematurely, is far less 
hopeful. 

G. Ernest Herman. 

REFERENCES 

1. Baudry, Annales cle Gynecologie,3m\\eXl%^^. — 2. Broers. Virchoio's Archiv, 
Bd. cxli. July 1895. — 3. Duncan, Matthews. Obstet. Trans, vol. xxxi. — 4. Helme, 
T. A. Trans. Royal Society Ed. vol. xxxv. Part 11, No. 8. — 5. Herman, G. Ernest. 
Obstet. Trans, vols. xxix. xxxi. — 6. Kelly. American System of Gynpcology and 
Obstetrics, art. "Injuries and Lacerations of the Perineum and Pelvic Floor." — 7. 
Klebs. Handbuch der pathologische Anatomic, p. 879.-8. Kloe. Patholojlcal 



EXTRA-UTERINE GESTATION 451 

Anatomy of the Female Sexual Organs, translated by Kammerer and Dawson, 1868, 
p. 127. — 9. Neugebauer. Arch, fiir Gyn. Bd. xxxiv. — 10. Ramsbotham, F. H. 
Obstet. Med. and Surgery. — 11. Ries. Zeit. fur Geb. and Gyn. Bd. xxiv. — 12. Schatz. 
Arch, fur Gyn. Bd. xxii. 1881, S. 298. — 13. Simpson, Sir James. Works, vol. iii. 
p. 602. — 14. Skene. New York Med. Journal, March 11, 1885. — 15. Williams, Sir 
J. Obstet. Trans, vol. xx. — 16. Williams, Sir J. Brit. Med. Jour. 1882, vol. ii. 
See also, on Rupture of Perineum, Duncan, Matthews. Papers on the Female 
Perineum, and on Methods Proposed to Pi'event it, Mbrkerttschiantz, Arch, fiir 
Gyn. Bd. xxvi., and Leishman, Glasgow Medical Journal, 1860. On Lacerations of 
Vagina, Freund, Gyndkolog. Klinik. On Puerperal Atrophy of Uterus, Thorn, 
Zeit. fiir Geb. und Gyn. Bd. xvi. ; Frommel, Zeit. fiir Geb. und Gyn. Bd. vii.; RiES, 
Zeit. fiir Geb. und Gyn. Bd. xxvii.; Gottschalk, Volkmann's Vortrage, N. F. 49. 

G. E. H. 



EXTEA-UTERINE GESTATION 

Normal pregnancy, or the state of " being with young," is the outcome 
of two factors — i. Impregnation, ii. The retention of an oosperm in 
the cavity of the uterus. 

In order to reach the uterine cavity the ovum must traverse the 
Fallopian tube. When an oosperm (fertilised ovum) is retained in the 
tube it continues to develop, and gives rise to the condition known as 
tubal pregnancy. 

The causes of tubal pregnancy are unknown ; and our ignorance 
will continue until we have some trustworthy information concerning 
the situation in the genital passages where ovum and spermatozoon 
normally meet. It is probable that fertilisation normally happens in 
the uterus, and that when it occurs in the tube it is accidental, and 
tubal gestation the consequence. 

Obstruction to the transit of ova will not explain matters, for an 
oosperm is more often retained in the wide ampullary section of the tube 
than in its uterine segment. My own observations teach me that tubal 
pregnancy is the result of active rather than of obstructive causes. The 
union of a spermatozoon with the nucleus of an ovum not merely initiates, 
in the previously passive cell, most marvellous and rapid changes ending, 
under favourable conditions, in the production of a new individual ; but 
in some unknown way exerts also an extraordinary influence on the re- 
productive organs. Hence it is probable that when an ovum is fertil- 
ised, the resulting oosperm engrafts itself at once on the adjacent 
mucous membrane, whether tubal or uterine. 

Tubal pregnancy may happen as a first pregnancy in women who 
have been married eight, ten, or even twenty years. A woman, thirty- 
seven years of age, from whom I removed a gravid tube five weeks after 
primary rupture, had been twice married, and her matrimonial life had 
extended over seventeen years ; yet her first pregnancy was tubal. Tubal 



452 



SYSTEM OF GYNECOLOGY 



pregnancy may follow normal gestation, or an abortion, within a few 
months ; or it may occur as a first pregnancy in a woman of twenty or 
forty years. A Fallopian tube may become gravid in the newly married, 
or in the mother of a large family. Both tubes may, in very exceptional 
instances, he gravid concurrently ; or one tube may become pregnant years 
after its fellow. In very rare cases two oosperms are retained in the same 
Fallopian tube — twin tubal pregnancy ; or again, tubal may complicate uterine 
pregnancy. An analysis of a large number of cases establishes the fact 
that the occurrence of tubal pregnancy is often preceded by a long in- 
terval of sterility. As this last statement is often used in an uncertain 
manner, it will be useful to attach some definite meaning to it. 

Matthews Duncan, from a careful consideration of 3722 cases of 
delivery, came to the conclusion, '^ that there is no good presumption of 
sterility until the fourth year of married life has been entered upon," 
and the accompanying table shows the intervals between marriage and 
the birth of the first child in his collected cases : — 



Less than 

one year 

1 ,, 


} 


608 
2390 


2 „ 




437 


3 „ 




133 


4 „ 

5 n 




61 
32 


6 ,, 

7 „ 




27 
12 


8 „ 




5 



9 years 5 



10 


, 1 


11 


, 3 


12 


, 4 


13 


, 2 


14 


, 


15 


, 1 


16 


, 


17 


, 


18 


, 1 



Taking these facts as a basis it will be convenient, in considering 
tubal pregnancy, to regard an unfruitful interval of four years after 
cohabitation as a " period of sterility " ; eight years would be a long, 
and sixteen years a very long period of sterility. 

In order to obtain further evidence in relation to this matter, I 
collected 100 cases of tubal pregnancy reported in American, British, 
French, and German literature, in order to determine as nearly as possi- 
ble the most common period of life for this accident. The cases were 
distributed thus : — 

Between the ages of 20 and 25, 10 cases. 
„ ,, 25 and 40, 86 „ 

,, ,, 40 and 45, 4 ,, 

100 „ 



The number of cases within each lustrum, 25-30, 30-35, 35-40, 
were almost equally distributed : I have further tested the conclusion 
by reference to my own cases, and those I have witnessed in the prac- 
tice of my colleagues, and the results are very constant. 

In regard to uterine gestation, Matthews Duncan points out that the 
interval 25-35 may be regarded as the great child-bearing period of life, 



EXTRA-UTERINE GESTATION 453 

and that the average duration of the child-bearing period is twelve years. 
I may add that in some eases in the lustrum 35-40 the foetus had been 
sequestered in the mesometrium (broad ligament) for several years, so that 
the period of functional activity of the uterus represents also the period 
of liability of the tubes to become gravid. 

Clinical experience has taught me that these facts in regard to age, 
child-birth, and a preceding " period of sterility," are points to be con- 
sidered in dealing with suspected cases of tubal pregnancy. 

The occurrence of pregnancy in the Fallopian tubes after a long period 
of sterility in women who have borne children, has led some writers to 
believe that these patients had suffered from desquamative salpingitis, 
and that the destruction of the tubal epithelium had hindered the ovum 
in its passage to the uterus. 

I have devoted much labour to the investigation of the minute changes 
in the mucous membrane of gravid tubes. In some specimens there is 
evidence of old inflammation ; but it must be pointed out that salpingitis, 
so severe as to produce destruction of the tubal epithelium, causes profound 
changes in the tubes, and leads to stricture and complete occlusion of their 
abdominal ostia ; when the tubes are denuded of their epithelium it is 
exceedingly rare to find the abdominal ostia patent. It is, however, 
well to bear in mind that salpingitis, even of a mild type, may so affect 
the tubal mucous membrane as to retard or altogether hinder the transit 
of ova; and an examination of pregnant tubes shows that salpingitis of a 
mild type, and without even partial destruction of the epithelium, will 
lead to the detention of ova and expose them to spermatozoa, which may 
wander into the tubes. On the other hand, in many specimens of very 
early tubal pregnancy I have failed, even after the most careful micro- 
scopic examination, to find any evidence of old salpingitis or loss of 
epithelium. 

It is probable that in a small proportion of cases chronic salpingitis 
of a mild type may account for the sterility and the subsequent tubal 
pregnancy ; but it fails to account for a very large number of instances. 
Indeed the evidence now indicates that a healthy Fallopian tube is 
more liable to become gravid than one which has been inflamed. 
Chronic salpingitis becomes even less satisfactory as an explanation of 
tubal pregnancy, when we reflect that, in some of the specimens, the 
inflammatory changes are the consequence rather than the cause of 
tubal pregnancy. Although changes of this character, or mechanical 
conditions induced by the presence of ovarian, parovarian, or uterine 
tumours, may explain a few cases, the causes of tubal pregnancy in 
most cases remain undetected. 

Our knowledge of the events consequent on the retention of an 
oosperm in the tube is fairly complete ; and, as they vary according to 
its position, gestation in the ampulla and the isthmus is called tuhal^ and 
in the portion which traverses the uterine wall tiibo-uterine pregnancy. 
This latter variety will require separate consideration. 

The stages of tubal pregnancy will be discussed in sections thus : — 



454 SYSTEM OF GYNECOLOGY 

i. Changes in the tube. ii. The tubal mole. iii. Tubal abortion, iv. 
Tubal rupture, v. The decidua and the placenta. 

i. The Changes in the Tube. — During the first month or six weeks that 
portion of the tube in which the oosperm is lodged becomes very vascular 
and turgid. Occasionally the walls of the tube, at the site where the 
villi are implanted on the mucous membrane, stretch and grow thin from 
the beginning of the gestation. The rapidity of the thinning varies in 
different tubes; this is due to the fact that under normal conditions 
the Fallopian tubes vary not only in length but in thickness. In some 
individuals they scarcely exceed in thickness the vasa deferentia of the 
male, and resemble rather the narrow tubes of the mare or cow. As 
the tube expands from the growth of the foetus and its membranes, the 
mucous membrane is stretched and its folds effaced. Occasionally a few 
of the plicae will project within the tube as long straggling processes. 

Whilst these changes are in progress curious alterations are taking 
place at the abdominal ostium, which, in many cases, gradually bring 

about its occlusion ; an event usually com- 
pleted by the eighth week. During the 
first four weeks the congestion of the parts 
causes turgescence of the fimbriae, as well 
as of the muscular and serous tissues ad- 
jacent to them. When the parts are thus 
swollen the margin of peritoneum adjacent 
to the ostium is very conspicuous, and 
forms an irregular ring around the fimbriae. 
In another fourteen days this ring projects 
beyond the fimbriae; lastly, it contracts and 
hermetically closes the ostium. 
Fig. 129. -Dilated abdominal ostium: Careful observations of gravid tubes 

from a gravid mole-containing tube. SCrVC tO sllOW that OCClusioU of the abdomi- 

{mit. Size.) ^^^1 ostium is by no means a constant sequel 

of tubal gestation ; indeed, in some instances, as the tube is distended by 
the growing embryo, the ostium dilates : I have examined specimens in 
which the abdominal ostium appeared as a circular opening 4 cm. in 
diameter (Fig. 129). It would appear that, when the oosperm is retained 
near the abdominal ostium, this aperture is more likely to become 
occluded than when it is lodged near the middle of the tube. When 
the oosperm is detained in the inner third of the tube the ostium is 
unaffected (Fig. 130). 

The condition of the mouth of the tube in some measure influences 
the subsequent course of the pregnancy, inasmuch as a widely expanded 
ostium disposes to tubal abortion ; but a gravid tube with a patent ab- 
dominal ostium is also liable to rupture. A gravid tube with an occluded 
ostium almost invariably bursts. 

Our knowledge of the condition of the uterine segment of the tube 
in cases of tubal pregnancy is less precise than that of the abdominal 
ostium, because mere examination with the naked eye, or such rough 




EXTRA- UTERINE GES TA TION 



455 



methods as the introduction of a probe, or a bristle, are not satisfactory 
tests. The best means of investigation consist in the microscopical 
examination of thin sections of the uterine segment of the tube. This 
has been carried out in a few instances, and the lumen of the tube found 
to be uninterrupted. 

The condition of the uterine segment of the tube is of some importance 
in connection with the clinical features of tubal gestation. It was assumed, 
by some of the older writers on extra-uterine gestation, that obstruction 
in this part of the tube would help to explain retention of the ovum in 
the tube. This is of course untenable, because it would likewise prevent 
the entrance of spermatozoa into the tube. In many cases of tubal 



Gestation sac 



Parovarium 



Ostium 




Corpus luteum Punctum 

Fig. 130. — Gravid tube ; the gestation sac occupied the uterine segment of the tube. The mole was 
equal to a green pea in size. The abdominal ostium was patent. {Nat. size.) 



gestation the patient complains of irregular discharges of blood from the 
vagina; this seems to be observed more especially in cases of tubal 
abortion. It is probable that some of this blood is effused into the tube 
and trickles through the uterine orifice into the cavity of the uterus. 

Tubal Moles. — The changes which occur in the oosperm subsequent to 
impregnation are identical, whether it be retained in the tube or the 
uterine cavity. In either situation it is liable to a curious change whereby 
it is converted into what is known as a mole. 

Practitioners are familiar with uterine moles : they are so common 
that most pathological museums contain several specimens, and few 
matrons terminate. the reproductive period of life without having pro- 
duced one or more examples of the fleshy mole. The clinical name 
for the event is "abortion." When a mole is examined soon after its 



456 



SYSTEM OF GYNECOLOGY 



discharge it resembles a firm blood-clot in colour and consistence. On 
dividing it, a cavity is found containing fluid, which, is sometimes straw- 
coloured, sometimes stained red from admixture with blood. The walls 
of this cavity are smooth and lined with amnion, and often a misshapen 

foetus is contained with- 



Chorion 



Clot 



Ammion 



Embryo 




in, or the stump of an um- 
bilical cord ; frequently, 
however, there is no trace 
of an embryo. 

In 1889 I was able to 
demonstrate that moles 
occur in connection with 
tubal pregnancy ; and 
since that date such a 
large number of exam- 
ples have been described 
that the tubal mole has 
become a familiar object. 

F,G. 131. -Tubal mole in section. (Vai. size.) rpj^^ characters of tu- 

bal moles may be summarised thus : — 

Tubal moles vary greatly in size ; some have a diameter of 1 cm., 
others of 5 or even 8 cm. Small moles are globular, but after attaining 
a diameter of 3 cm. they assume an ovoid shape. 

The amniotic cavity usually occupies an excentric position (Fig. 131). 
Occasionally an embryo is present ; often it is misshapen and ill-developed. 

In a great many specimens, owing to the excentric position of the 
amniotic cavity, its walls are ruptured and the embryo is lost. 

The outer investing membrane — the chorion — is usually shaggy with 
villi, which become more obvious if the mole be exposed to a gentle 
stream of water. 

In some specimens the amniotic cavity is effaced ; if such moles be 
sectioned and examined microscopically, the chorionic villi will be found 
cut transversely or obliquely. 

Eecent moles resemble a piece of blood coagulum and are dark red. 
When they have been free in the peritoneal cavity (coelom) or lodged 
between the layers of the mesometrium (broad ligament) for days or 
weeks they are sometimes yellow externally, and often firm and hard. 

The majority of tubal moles are easily recognised; but a doubt may 
arise when the amniotic cavity is obliterated. In a doubtful case of this 
kind the presence of chorionic villi determines its nature. The villi 
usually appear as clusters of circular bodies ; ten or more may, in fortunate 
sections, be counted together : more frequently they occur in groups of 
three or four, and often a wide section of clot may be examined without 
finding more than two or three. Under a low power they present an 
external layer of epithelium, the central space being occupied by irregular- 
shaped cells (Fig. 132). When examined under high powers a limiting 
layer of cubical epithelium, forming a perfectly regular row, is often to be 



EXTRA- UTERINE GES TA TION 



457 



seen. Sometimes the interior of a villus resembles the stratum inter- 
medium of an enamel organ. In larger villi there is often a double row 
of epithelium. 

The structure and mode of formation of these moles are of great 
interest. In the early stages of development the relations of the mem- 
branes are somewhat different to those which obtain at a later period, and 
it is a significant fact that moles only arise in the first few weeks following 



CHORIONIC 
VILL 




Fig. 132. — Microscopical characters of chorionic villi in section, in blood-clot. 



fertilisation. Soon after the chorion is shaggy with villi the embryo will 
be found in the amnion ; between the amnion and the chorion a space ex- 
ists (which may be called the subchorionic chamber) filled with albuminous 
fluid (Fig. 133). As the embryo increases in size the amnion gradually 
encroaches on this space and eventually obliterates it ; but for a time a 
potential space exists between the two membranes (Fig. 134) exactly 
resembling that between the visceral and parietal pleurae. 

The most cursory examination of a typical tubal mole will convince 
the observer that the blood is limited externally by the chorion and 
internally by the amnion (Fig. 131). It is obvious that this hlood occupies 



458 



SYSTEM OF GYNAECOLOGY 



the subcJiorionic chamber. This at once explains the elliptical shape of 
large tubal moles. 

We have now to determine the source of the blood. Many observers 
have hitherto been content to believe that a mole is formed by an irruption 
of maternal blood into the embryonic membranes. In the face of the 
observed facts mentioned above this loose opinion falls to the ground. 
The blood is furnished by the circulation of the embryo. This viev^ is 
further supported by the character of the blood : the blood of the embryo 
differs from that of the adult by the fact that the red corpuscles are 
nucleated ; now actual observations on blood from fresh tubal moles show 
that the red corpuscles are nucleated. 

It is clear that a tubal mole is due to blood extravasated from the cir- 
cidation of the embryo into the subchorionic chamber. 




Amniotic cavity 
Amnion 



Subchorionic 
chambers 



Chorion 




Fig. 133. —Diagram to show the early relationa 
of the amnion and chorion and the sub- 
chorionic chamber. 



Fig. 184. — An early tubal embryo, 
showing the polar disposition of 
the villi, etc. {N^at. size.) 



It must be distinctly understood that these observations only apply 
to blood within the chorion. It does not follow that the blood found 
within the subchorionic chamber is the result of a single haemorrhage ; 
careful examination of tubal moles demonstrates that the blood is often 
disposed in laminse like that found in a sacculated aneurysm. This is 
sufficient to prove that in some instances, at least, the formation of a 
tubal mole is a gradual process. 

In many cases tubal moles are found immersed in blood extravasated 
from the maternal vessels. Occasionally mole-containing tubes come 
to hand in which no blood is effused between the chorion and the tube. 
In such cases evidence that the blood comes from some source within 
the chorion is irrefragable. 

Tubal Abortion. — It has been pointed out already that the presence 
of an oosperm in the outer third of a Eallopian tube usually leads to 
occlusion of the abdominal ostium : this event is commonly complete by 



EXTRA-UTERINE GESTATION 459 

the end of the sixth week ; sometimes it is delayed to the eighth week ; 
it is therefore a comparatively slow process. 

So long as this orilice remains open the oosperm is in constant jeopardy 
of extrusion through it into the peritoneal cavity (coelom), especially when 
it lies in the ampulla of the tube ; the nearer it is situated to the ostium 
the greater the chance of this extrusion. To this accident the term 
''tubal abortion" is applied, for it is exactly parallel to those early 
abortions occurring in uterine gestation before the end of the second 
month ; and it further resembles them in the fact that the oosperm is 
nearly always converted into a mole. 

The term tubal- abortion is applicable to cases in which haemorrhage 
takes place from a gravid tube, the blood entering the coelom through 
an unclosed ostium. 

Many of these cases resemble early uterine abortions in which a mole 
is expelled, accompanied by a free discharge of blood from the uterus. 
In tubal abortion the same thing happens. The mole is discharged with 
a copious haemorrhage into the peritoneal cavity through the ostium ; the 
patient presents the usual signs of internal bleeding, and rapid death may 
occur from the consequent anaemia, or from shock. In such instances 
the mole, being very small, often escapes recognition when the clot is 
examined, whether after an operation or after death. Tubal abortion can 
only occur during the first two months ; for when the ostium is occluded 
the blood cannot escape without rupture of the sac. The quantity of 
blood which flows from the tube into the peritoneal cavity sometimes 
amounts to two, three, or even four litres. Tubal abortion is a subject 
of much interest, inasmuch as it furnishes many of the cases of pelvic 
haematocele which are ascribed to metrorrhagia, reflux of menstrual blood 
from the uterus, or haemorrhage from the mucous membrane of the Fallo- 
pian tube. The reason for associating the haemorrhage with metrorrhagia 
and menstruation is due to the fact that, whilst the embryo is growing in 
the tube a decidua is forming in the uterus. When tubal abortion occurs 
haemorrhage takes place from the uterus, consequent on the separation 
and expulsion of the decidua. Should this accident happen near the time 
the patient expects to menstruate, the case would be regarded as reflux 
of menstrual fluid into the peritoneum. In some cases the blood dis- 
charged from the uterus is derived from the gravid tube ; this especially 
happens in cases of protracted tubal abortion. If it do not coincide with 
a menstrual period it is then usually considered to be of uterine origin. 
It will therefore be well, in searching blood removed in abdominal opera- 
tions, to examine carefully any apparently organised ovoid clot, in order 
to ascertain whether it contain an amniotic cavity with or without an 
embryo, and also to ascertain the existence or otherwise of chorionic 
villi. 

It is necessary to bear in mind that in early uterine abortion the mole 
often fails to become completely detached from the uterine wall ; bleed- 
ing recurs so long as the mole is retained. In tubal pregnancy the same 
thing happens ; the mole, so long as it is not ejected from the tube, gives 




46o SYSTEM OF GYNAECOLOGY 

rise to recurrent haemorrhage (Fig. 135). This may be described as incom- 
plete tubal abortion, and is more common than the complete form. 

Doubts have been expressed in regard to the occurrence of complete 
tubal abortion. In 1892 I reported the details of such a case to the 
Medical Society of London. At the operation I found the mole lying 
among the fimbrise of the tube. There was a small rent in the tube wall. 
The tube, ovary, and mole are shown of natural size in Fig. 136. 

A few writers are disposed to quibble over the term tubal abortion. 

There can be little doubt that it 
will be possible in the future to dis- 
tinguish clinically between rupture 
of a gravid tube and incomplete 
tubal abortion ; the latter condition 
certainly gives rise to repeated 
bleeding. Besides this, the full rec- 
ognition of the fact that a mole 
may be discharged through an un- 
closed ostium into the peritoneal 

Fm. 135. -A gravid tube with patentTITium; the ^avity haS helped tO Complete the 
mole is shown in section. From a case of in-, cliaiu of Cvidcnce that pclvic hSBma- 
complete tubal abortion, i^at. si.e.) ^^^^^^^ ^^^^ ^j^^.^ ^^^^^^ .^^ h^mOT- 

rhages from gravid Fallopian tubes. 

In tubal abortion the great danger lies in the fact that the bleeding 
is apt to be recurrent, so long as the mole is retained in the tube. Noble 
has recorded briefly the details of a case of tubal abortion in which the 
blood-clots found in the pelvis were " coiled up much as though they 
had been ground through a sausage machine " ; the blood clotted in the 
tube, and the clot was then forced out as a sausage-shaped mass by the 
continuance of the bleeding. 

It is a noteworthy feature in many instances of incomplete tubal 
abortion that the mole very firmly retains it attachment to the tube wall 
(Fig. 135) ; the area of fixation corresponding to the placental site. In 
my early investigations into the nature of tubal moles I found that villi 
occurred abundantly in sections taken from one part, and yet were absent 
in those taken from other parts of the same mole. Since I detected the 
striking polar congregation of villi displayed in Fig. 134, 1 have always 
taken my sections from the adherent pole, and have so far never failed 
to find the villi in great force. 

Rupture of the Gestation Sac. — Abortion of a gravid tube, as 
described in the foregoing section, is a very common termination of 
tubal pregnancy. Failing this the gestation sac almost invariably bursts, 
the only exception being the very rare event of a mole lying quiescent 
in the tube. 

Eupture of the tube will be discussed in the sections indicated in 
the subjoined table : — 

1. Primary rupture — (a) Intraperitoneal ; (6) extraperitoneal. 

2. Secondary rupture — (a) Intraperitoneal ; (6) extraperitoneal. 



EXTRA- UTERINE GES TA TION 



461 



Primary Rupture. — This term refers to the rupture of the tube which, 
in the majority of cases, occurs at some period between the third and 
tenth week after impregnation, and is rarely deferred beyond the twelfth 
week. 

The predisposing causes of rupture are the gradual thinning of the 



BAL-HOLE 




Fig. 136. — Fallopian tube and ovary, mole and corpus luteuin from a case of complete tubal abortion. 

(^«^. size.) 

walls of the gestation sac as the embryo grows, and the undue dis- 
tension of the membranes by haemorrhage. Muret has pointed out, 
in a very careful study of specimens, that the thinning is especially 
marked at the seat of implantation of the chorionic villi. Eupture is 
sometimes produced by violence, such as jumping from a train, stool, or 
carriage ; straining during vomiting or defsecation, or sexual congress. 



462 SYSTEM OF GYNECOLOGY 

Before considering this event in detail, we may for a moment study 
the relation of the Eallopian tube to the mesometrium (broad ligament). 
The healthy tubes in the human female occupy the free borders of this 
structure, and, on two-thirds of their circumference, are invested by it ; 
indeed the tube is held in position by a peritoneal investment resembling 
the mesentery. The portion of the mesometrium adjacent to the tube 
is appropriately termed the mesosalpinx. 

When the tube becomes enlarged in consequence of inflammation, or 
dilated by an embryo growing within its lumen, the layers of the meso- 
salpinx are separated by the enlarging tube. 

This separation of the layers of the mesosalpinx, however, does not 
occur along the whole extent of the tube, but is restricted mainly to its 
middle third. It is important to realise this, because it explains the 
frequency of intraperitoneal rupture, when the embryo is situated in the 
outer third of the tube. The anatomical evidence alone leads us to expect 
that when a pregnant tube bursts, the chances of this accident including 
the serous covering would be greatly in excess when the rupture takes 
place in the uncovered portion ; and, as a matter of fact, intraperitoneal 
is to extraperitoneal rupture in the proportion of three to one. 

In primary intraperitoneal rupture the embryo and its membranes, or 
a mole accompanied by a variable amount of blood, may be discharged 
directly into the coelom. The quantity of blood extravasated depends 
upon the date of rupture. When this occurs early, the blood extrava- 
sated may amount to a few ounces ; but after the first month it is 
usually very copious, and frequently causes death in a few hours. When 
rupture is deferred until the seventh week the embryo (or the mole) is 
not constantly discharged through the rent; and as the walls of the 
gestation sac are prevented from contracting, the amount of blood which 
escapes is often very large. When the haemorrhage is moderate in 
amount, and the patient escapes the immediate dangers incidental to the 
accident, especially shock, the effused blood may undergo partial absorp- 
tion and recovery ensue. When the bleeding is not excessive, the blood 
collects in the recto-vaginal fossa and floats up the coils of intestines. 
These, with the omentum, gradually form a covering to the fossa by 
adhering together ; so that the blood in the pelvis is isolated from the 
general peritoneal cavity (coelom). Unless haemorrhage recur the fluid 
portion of the blood is slowly absorbed, and the patient recovers ; but 
convalescence is very tardy. 

Taylor has reported some valuable cases in which he demonstrates 
clearly enough that in some instances the blood undergoes coagulation in 
layers and forms a sort of spurious cyst. In my experience the walls 
of these spurious cavities resemble the laminated arrangement familiar 
to surgeons in the parietes of a hsematocele of the tunica vaginalis testis. 

The dangers of primary intraperitoneal rupture are : — i. Rapid death 
from haemorrhage, ii. A fatal result from repeated haemorrhage. 

Primary Extraperitoneal Rupture. — In a certain proportion of cases 
the tube ruptures through that portion of its circumference which lies 



EXTRA-UTERINE GESTATION 463 

between the separated layers of the mesosalpinx. When this happens 
the mole and a varying amount of blood are forced into the connective 
tissne between the layers of the mesometrinm (broad ligament). In most 
cases this is fortunate for the patient, as the bleeding is checked by the 
pressure exerted by the resistance which occurs as the mesometric tissue 
becomes distended, and is arrested before it assumes dangerous propor- 
tions. Thus the blood and mole are entombed, as it were, in the 
mesometrinm, and rarely cause subsequent trouble. 

Rupture may take place and the embryo with its membranes remain 
uninjured and the pregnancy continue ; for, no longer confined within 
the narrow limits of the tube, it begins to avail itself of the additional 
space thus offered, and burrows, as it grows, between the layers of the 
mesometrinm. 

From the manner in which this mode of rupture is sometimes de- 
scribed it might be imagined that the tube splits, and that the products 
of gestation are suddenly discharged from the tube into the mesometrinm. 
This is not the case, or the pregnancy would in every instance come to 
an end from the dissociation of the foetal from the maternal structures. 
So far as I have been able to study the morbid anatomy of the accident, 
the slow and gradual distension of tlie tube causes it to thin and gradu- 
ally yield in the part of its circumference uncovered by peritoneum until 
an opening forms, accompanied by sudden haemorrhage ; this produces 
collapse, the profundity and duration of which depend upon the amount 
of blood that escapes. This artificial opening gradually extends until 
the growing embryo and placenta make their way into the new area of 
connective tissue thus opened up, and by degrees occupy it, unless the 
life of the embryo be terminated by renewed haemorrhage. 

When pregnancy continues in this way it is spoken of as a '' meso- 
metric gestation," because the sac is formed in part by the expanded 
Fallopian tube and the layers of peritoneum forming the mesometrinm. 

Dezeimeris described the development of an extra-uterine foetus in 
this situation as far back as 1836, and Parry draws attention to it 
thus : — 

" By subperitoneo-pelvic (sous-peritone-pelvienne) pregnancy Dezei- 
meris intended to designate a variety in which the ovum, after quitting 
the ovarian vesicle, did not enter the Fallopian tube nor fall into the 
peritoneal cavity, but, on the contrary, passed between the two folds of 
the broad ligament, and there developed. According to this view the 
product of conception is situated outside the cavity of the peritoneum. 
That the ovum has been found in this locality cannot be doubted, but 
when such is the case there is every reason to believe that it reaches 
this peculiar situation through rupture of a tubal cyst, in Avhich the 
integrity of the peritoneum was not destroyed, so that the ovum escaped 
between the two layers of the broad ligament, where it continued to 
develop. It is therefore one of the terminations of an ordinary tubal 
:ion." 

Subsequent observation on this head has not only justified Parry's 



464 SYSTEM OF GYNECOLOGY 

opinion, but demonstrated the fact that in all tubal pregnancies which 
survive the primary rupture and continue their development, the gesta- 
tion sac is formed in part by the expanded tube, but mainly by the layers 
of the mesometrium. The proper appreciation of this fact has done 
much to simplify our knowledge of tubal pregnancy ; and no one has 
more strongly insisted upon its correctness than Lawson Tait. 

It is clear from a study of Dezeimeris' paper that his observation 
was of a very casual sort, and he certainly failed to appreciate its 
importance. 

The Placenta and Deddiia. — In tubal gestation the placenta is liable 
to many vicissitudes which very materially influence the life of the 
foetus, as well as that of the mother ; and as in many cases it is a source 
of anxiety to the surgeon, it is imperative upon those who may be called 
upon to deal clinically with tubal gestation to consider the subject with 
more than ordinary care. 

The placenta formed in tubal gestation differs in several particulars 
from one developed in the uterus. In normal gestation the uterine 
mucous membrane is supposed to take a large and important share in 
forming the placenta ; but, so far as I can judge from my own observa- 
tions, the tubal mucous membrane plays a very insignificant part when 
pregnancy occurs in the tube. 

The fully developed uterine placenta is composed of parts derived 
from the maternal and foetal tissues in nearly equal parts; a tubal 
placenta is mainly if not entirely derived from the foetal tissues. 

Clarence Webster has endeavoured to show that certain changes 
which he describes in the deep layers of the mucosa of gravid tubes 
represent a decidual formation. From a thorough, careful, and repeated 
microscopical examination of gravid tubes in exceptionally early stages 
of pregnancy I have failed to find anything that can be regarded as a 
tubal decidua, certainly nothing that is cast off in the form of a mem- 
brane, and this is an essential qualification for a decidua. 

The Uterine Decidua. — It is a curious circumstance in tubal preg- 
nancy that, though no decidua forms in the tube, a decidua forms in the 
uterus. Few facts have been so much disputed as this, and the discussions 
will be found in Parry's classical work. The conclusions of Parry have 
been confirmed by those who have studied the subject in recent years. 

My own observations are so thoroughly consonant with those of 
Parry that his views will be given in his own words : — 

"1. In all varieties of extra-uterine pregnancy a decidua forms in 
the uterine cavity, as in normal gestation, but none is found in the tube. 

'' 2. The decidua is rarely retained until the completion of gestation, 
and thrown off during false labour. More frequently, if the patient goes 
to term, it is discharged during the early periods of pregnancy in small 
fragments and without producing pain ; or else it is expelled en masse 
with symptoms of miscarriage. 

" 3. The absence of a uterine decidua when death has occurred from 
rupture of the cyst, even in the early stages of pregnancy, is not proof 



EXTRA-UTERINE GESTATION 465 

that the membrane has not been formed, but simply that it has been 
expelled before the death of the foetus." 

It is an interesting and curious fact that when pregnancy occurs in 
cne-half of a bicorned uterus, a decidua forms in the unimpregnated 
cornu. I have myself observed that a similar condition holds good in 
animals normally possessed of bicorned uteri (for example, in ungulates 
and lemurs). In normal pregnancy no decidua forms in the Fallopian 
tubes or in the cervical canal. It is now well established that the destruc- 
tive changes which occur in the mucous membrane of the genital tract 
in association with menstruation are limited to the lining of the cavity 
of the uterus ; and that the formation of a true decidua is limited to 
that part of the genital tract which undergoes the destructive changes 
associated with menstruation and rut. 

It is important not to confound a decidua of pregnancy with a decidua 
occurring in what is called membranous dys- 
menorrhcea. Menstrual decidace rarely exceed 
2 or 3 cm. in length, and are scarcely 2 mm. 
in thickness. As a rule they are translucent, 
and rarely passed entire. The deciduce of preg- 
nancy are larger, and vary in thickness 6 to 
8 mm. They may be described as bags re- 
sembling in outline an isosceles triangle. The 
base corresponds to the fundus of the uterus, 
and the apex to the internal opening of the 
cervical canal. At each angle of the triangle 
there is an opening. Those at the basal 
angles correspond to the Fallopian tubes, and ea»"AuWp,.Srnct\'Z/S" 
the apical orifice to the cervical canal. The 

outer aspect is shaggy, and the inner surface is dotted with the orifices 
of uterine glands. The angle corresponding to the internal orifice of 
the cervical canal is often represented by a large opening (Fig. 137). 

Up to the period of primary rupture the formation of the placenta 
has been proceeding in relation with the mucous membrane of the Fallo- 
pian tube ; but after this event, if the disturbance of the parts be not so 
great as to terminate the pregnancy, the course of events is modified in 
a remarkable manner. We are indebted largely to the admirable inves- 
tigations of Drs. Berry Hart and Carter for the facts upon which this 
account is based. After primary rupture of the tube the embryo and 
placenta (when the development is sufficiently advanced) gradually occupy 
a sac formed by the expanded tube and separated layers of the meso- 
metrium, the floor of this space being formed by connective tissue and 
the levator ani muscle. 

The ultimate effects of this gradual dislocation of the embryo and 
placenta depend mainly upon the original position of the placenta. 
Dr. Hart points out that if the embryo lie above the placenta, the 
latter becomes depressed between the layers of the mesometrium until 
it is arrested by the pelvic floor. If, on the contrary, the embryo lies 

2h 




466 



SYSTEM OF GYNECOLOGY 



below the placenta, the embryo in its membranes burrows between the 
layers of the mesoraetrium, and the placenta is pushed up by the growing 
embryo until it lies high in the abdomen (Figs. 138 and 139). He has 
had opportunities of investigating the structure of these extra-uterine 
placentae, and points out that in tubal gestation the villi lie embedded 
in decidual cells, and no intervillous sinus system seems to exist. Large 
sinuses, however, form in the muscular wall. The villi are well formed, 
and are covered with perfect epithelium. The decidual cells are large, 
and have a large nucleus and nucleolus. When the placenta is displaced 
into the mesometric tissue — and we must bear in mind that this displace- 
ment occurs gradually — the placental structure becomes seriously 




Foetus 



Levator ani 



Fig. 138. —Transverse section of the pelvis of a woman with an embryo and placenta of the fourth 
month of gestation occupying the rig-ht mesometrium. (After Berry Hart.) 

damaged. The villi are less perfect in contour, blood extravasation is 
present, blood crystals are abundant, and the decidual cells few and 
less perfect. 

Dr. Hart's observations lead him to conclude, that on the displace- 
ment of the placenta from mucous membrane to connective tissue, 
the placenta is gradually reduced to a mass of compressed villi, the 
serotina is destroyed, and is replaced by blood crystals and organising 
blood-clot. The least damage is sustained by the placenta when the 
embryo is situated above it, because under such conditions it undergoes 
the minimum amount of displacement. The extreme disorganisation to 
which the placenta is liable when it forms the roof of the gestation sac 
may be studied even in the early stage of the pregnancy. 



EX TRA- U 7 'ERINE GES TA TION 



467 



It must be obvious that a placenta when displaced in this way must 
have its function very seriously hampered in comparison with one firmly 
deposited on the floor of the pelvis. It has been demonstrated histo- 
logically that there is great damage produced by this slow migration. 

It is of the utmost importance to appreciate correctly the structural 
alterations which occur in the placenta, consequent upon these remark- 



Liver 




Bladder 
Eectum 
Vagina 



Fig. 139. — Sagittal section of a cadaver, with a mesometrium pregnane}^ at term; it indicates the 
extreme displacement of the placenta. (After Berry 'Hart.) 

able displacements to which it is subject ; they exert a great influence 
on the subsequent history of the pregnancy, greatly imperil the life of 
the mother, and in most cases are disastrous to the life of the foetus. 

The danger in which such displacements of the placenta place the 
mother is this : — The constant tension to which the peritoneum cover- 
ing the gestation sac is subject may at any time cause it to yield, and 
lead to partial detachment of the placenta, and as a consequence to 



468 SYSTEM OF GYNECOLOGY 

severe haemorrhage, which may take place into the gestation sac, or 
more probably into the coelom. Such hsemorrhage in the late stages of 
these pregnancies is almost invariably fatal. Indeed, a woman with a 
mesometric pregnancy, with the placenta situated above the foetus, runs 
a far greater risk of losing her life than when she is the victim of the 
dreaded condition termed placenta prcevia. 

The Effects of Placental Migratioyi on the Foetus. — We have seen 
already that tubal placentae are less perfect organs than uterine placentae. 
Even when a tubal placenta lies below the embryo after rupture, its 
structure is so damaged as to make it an inefficient respiratory organ ; 
hence, when it is situated above the embryo, it must be much less 
adequate to the needs of the foetus, and subject to the grievous vicissi- 
tudes which have been already mentioned. 

The results on the embryo are very manifest. A foetus the product 
of a tubal gestation is a very unsatisfactory individual. Even when 
rescued by the surgeon at or near time, it rarely survives longer than a 
few days or weeks. In many cases these infants are ill-formed, and 
present hydrocephalus, club-foot, spina bifida, ectopia of the viscera, or 
similar deformity ; and, even when normal in shape, they are exceed- 
ingly defective in size. In one instance a tubal sac contained two 
embryos measuring 11 cm. in length, united by a band in the thoracic 
region (Thoracopagus). 

/Secondary Rupture. — When the pregnancy continues between the 
layers of the (mesometrium) broad ligament, the gestation sac may 
rupture at any moment; and the risk of this accident, so far as we can 
judge at present, is much greater when the placenta is situated above 
the foetus. As the pregnancy progresses, the peritoneum forming the 
sac becomes stretched and stripped from adjacent parts and from the 
viscera. Sometimes, as the sac extends into the abdomen, it will strip 
the peritoneum from the anterior abdominal wall, as in the case of an 
over-distended bladder, only to a much greater extent. When the 
serous membrane is stripped from the posterior aspect of the pelvis, 
the rectum may be deprived of its serous investment, as well as the 
posterior surface of the uterus, the foetus and placenta insinuating 
themselves between these parts beneath the peritoneum. 

At any period between the twelfth week and term the gradually 
thinning gestation sac may rupture. The effects of this accident vary. 
When the rent involves the placenta, as it is almost certain to do when 
this organ is situated above the foetus, and the gestation has advanced 
beyond the mid-period of pregnancy, terrible haemorrhage and a speedy 
death are the usual consequence ; before this date the haemorrhage may 
not always be so severe, and opportunities for surgical intervention may 
be found. When the sac bursts into the peritoneum in this way, it is 
spoken of as secondary intraperitoneal rupture. 

When the placenta occupies the pelvis, and the foetus the abdominal 
portion of the sac, the latter may become so slowly thinned that at last 
it yields, and the foetus disports itself among the intestines. 



EXTRA-UTERINE GESTATION 469 

It must be remembered that secondary rupture may be indefinitely 
delayed, and in some cases never occurs. The patient goes to term, 
passes through a spurious labour, the liquor amnii is absorbed, the 
placenta disappears, and the existence of an extra-uterine pregnancy is 
never suspected until a mummiiied foetus or a lithopaedion is discovered 
at the autopsy (see p. 472). 

Of the two forms of secondary rupture, the intraperitoneal variety 
may occur at any date between the twelfth week and term. 

Secondary intraperitoneal rupture near or at term must be discussed 
more fully, because these are the cases w^hich tend to perpetuate the 
belief that fertilised ova may tumble into the coelom and engraft 
themselves upon the serous membrane and develop. A critical inquiry 
into this matter has convinced me that there is no case on record w^hich 
can be cited as decisive proof of this occurrence. There is no such 
condition as a primary peritoneal pregnancy. All forms of extrcb-uterine 
gestation pass theAr primary stages in the Fallopian tube. 

I am of opinion that the so-called primary abdominal pregnancies are 
primary tubal ; gradually the tube opens out into the broad ligament, 
and as the pregnancy progresses to term the walls of the gestation sac 
rupture, and the foetus escapes into the coelom, as in the remarkable case 
recorded by Mr. Jessop : — 

" A woman twenty-six years of age believed herself two months 
pregnant ; she was suddenly seized with violent pain in the right side of 
the belly, which caused her to faint. From the effects of this trouble 
she kept her bed two months. Five months later, at a consultation, it 
was decided that she was a victim of extra-uterine gestation, and she was 
admitted into the Leeds Infirmary. As the woman w^as in a critical 
condition abdominal section was performed without delay. On cutting 
through the anterior wall of the belly, the breech and back of a child 
thickly coated with vernix caseosa came into view. The child had 
lodged in the midst of the bowels, free in the cavity of the abdomen. No 
trace of cyst or membrane could be discovered. The placenta Avas seen 
covering the inlet of the pelvis, like the lid of a pot, and extending some 
distance posteriorly above the brim, where it apparently had an attach- 
ment to the large bowel and posterior abdominal wall. The patient 
recovered from the operation, and the child lived for eleven months." 

From this case nothing positive can be inferred; fortunately the 
woman recovered, and the relation of the placenta to the gestation sac 
and the condition of the Fallopian tubes could not be ascertained. 

Similar cases have been described by Champneys, Taylor, and others. 

I have had one excellent opportunity of dissecting the pelvis of a 
woman who died after the removal of an extra-uterine foetus which had 
escaped from the gestation sac among the intestines. I was able to isolate 
the displaced layers of the right broad ligament forming the gestation 
sac, in which a large piece of amnion was retained. The placenta had 
occupied the pelvis and part of the posterior wall of the uterus beneath 
the peritoneum. The corresponding tube and ovary were not detected. 



470 



SYSTEM OF GYNECOLOGY 



Tubo-uterine Gestation. — When an oosperm lodges and develops in 
the section of the Fallopian tube which traverses the uterine wall, the 
gestation is termed tubo-uterine. This variety runs a somewhat dif- 
ferent course from the purely tubal form. 

Tubo-uterine gestation is somewhat rare ; many specimens described 
as belonging to this class turn out on critical examination to be speci- 
mens of cornual pregnancy. 

The occurrence of tubo-uterine gestation admits of no doubt what- 
ever ; and, fortunately, a few specimens exist of this accident which 
demonstrate its absolute independence of cornual pregnancy. Two 




Fig. 140. —Tubo-uterine gestation. (Museum, G-uy's Hospital.) 



specimens — one preserved in the museum of Guy's Hospital, and the 
other in the museum of the Eoyal College of Surgeons, which has had 
the advantage of careful investigation by Mr. Doran — are the most 
satisfactory and easily accessible examples in London. 

The specimen at Guy's is carefully described in the Reports of that 
hospital for 1860 by Dr. Braxton Hicks. 

Doran has described in detail a uterus obtained from a woman aged 
thirty-two years, who died from haemorrhage in about ten hours after 
rupture of the sac of a tubo-uterine gestation. An embryo enveloped in 
membranes, and corresponding to the second month of development, was 
found floating in blood in the abdominal cavity. 



EXTRA- UTERINE GES TA TION 



471 



Tubo-uterine gestation differs in its course, anatomy, and modes of 
termination from the purely tubal form. In tubal gestation primary 
rupture usually occurs about the eighth, and is rarely deferred beyond 
the twelfth week ; in the tubo-uterine variety it may be delayed much 
beyond this date. 

The date of rupture in four cases is given in the subjoined table — 

Braxton Hicks. — The development had probably proceeded to the end of the 

fourth month. 
Lawson Tait. — The patient thought she had turned the fourth month. 
Doran. — About the end of the second month. 
Author. — About the fifth week. 

The sac of a tubo-uterine gestation may rupture in two directions : 
It may burst into the coelom, and be rapidly fatal ; or into the 
uterine cavity, and be discharged like an ordinary uterine conception. 
It must be remembered that in this variety the sac does not rupture in 
such a way as to allow of the embryo being dislocated between the layers 
of the mesometrium. 

An examination of the clinical details of cases of undoubted tubo- 
uterine gestation indicates that intraperitoneal rupture of the sac is more 
rapidly fatal than the tubal form ; and that this is due to the greater 
amount of haemorrhage, because not only are the walls of the gestation 
sac thicker, but the rent often extends to and involves the uterine wall. 

As a means of ready reference the points in which the two varieties 
of tubal gestation differ from each other are arranged in tabular form : — 





Tubal. 


Tubo-uterine. 


Frequency. 


Very common. 


Very rare. 


Gestation sac. 


Walls are very thin. 


Walls very thick. 


Termination. 


(a) Intraperitoneal 


(a) Intraperitoneal 




rupture. 


rupture. 




(&) May rupture into 


(6) May rupture into 




the mesometric 


uterine cavity, and 




space. 


be discharged 




(c) May abort. 


through the vagina. 


Date of primary- 


At any date from the 


At any date from the 


rupture or abor- 


3rd to 12th week. 


5th to the 20th 


tion. 




week. 



Although in many examples of tubo-uterine gestation primary rupture 
may be delayed longer than in the purely tubal form, nevertheless the 
sac sometimes bursts very early. In these cases death from haemorrhage 
may follow within a few hours. 

Ovarian Pregnancy. — In writings on extra-uterine gestation it has 
been for man}^ years the custom to describe a variety known as " ovarian 
pregnancy," an event believed to be due to the fertilisation of an ovum 
before its escape from the ovarian follicle. 



472 SYSTEM OF GYNECOLOGY 

It is extraordinary that belief in the occurrence of ovarian pregnancy 
should have obtained currency. Those who care to take the trouble to 
study the evidence in support of it, especially that collected by Campbell, 
will find that some of the supposed examples were as a matter of fact 
ovarian dermoids, and that the others were based on the most flimsy 
examination. 

In the cases of supposed ovarian pregnancy published by observers of 
repute, like Martin and Leopold, the foetus in each instance had been 
many years sequestered in the mesometrium ; hence it is impossible to 
infer the relation of the gestation sac to the ovary with any certainty. 

In some English cases reported as ovarian pregnancy the opinion as 
to their situation in the ovary was based on the circumstance that at 
the autopsy the ovary was not seen ! Until some specimen is forth- 
coming in which an early embryo, in its membranes, can be demonstrated 
in a sac inside the ovary we need not trouble ourselves to discuss ovarian 
pregnancy. 

Retention of the Foetus. — In tubal pregnancy the life of the embryo, 
as has been shown in a preceding section, is very precarious. Yet in 
the face of all these possibilities the gestation may run on to term. 
Then symptoms of labour set in, and as delivery by the natural channels 
is impossible, the gestation sac may burst into the coelom, with all 
the attendant evils of this event. If it escape this catastrophe the 
foetus dies, and the body may either remain quiescent or may give rise 
to various forms of disturbance. 

In the more fortunate cases the unavailing labour is (p. 475) followed 
by absorption of the liquor amnii, and the tissues of the foetus may become 
mummified, or they may be partially calcified to form a lithopsedion ; the 
soft parts may be converted into adipocere, or the tissues may otherwise 
decompose. The placental tissues gradually and completely disappear. 

Mummification. — To produce this state the fluid parts become ab- 
sorbed, and the soft parts are converted into dry tissue, so that the foetus 
resembles a mummy, or the dried cats so commonly found under the 
floors of old dwellings. 

The length of time an extra-uterine foetus may be retained is some- 
times very great. In Cheston's celebrated case a lithopsedion was 
retained fifty-two years. Dr. Barnes reported a case in which a 
lithopsedion was retained forty-two years. 

A retained foetus may give trouble at any time. Pathogenetic micro- 
organisms obtain entrance to the sac from some of the adjacent hollow 
viscera (rectum, intestines, bladder, etc.) and establish suppuration. The 
pus may find its way through the abdominal wall or penetrate into the 
vagina, uterus, rectum, or bladder. Through fistulse thus formed frag- 
ments of foetal tissues from time to time escape. It has been demonstrated 
that a woman may have a lithopsedion or a macerated foetal skeleton in 
her mesometrium and yet conceive in the uterus. 

The Diagnosis of Tubal Pregnancy. — The symptoms of tubal gesta- 
tion vary considerably according to the stage to which gestation has 



EXTRA-UTERINE GESTATION 473 

advanced. It will be necessary, therefore, to deal with it in the following 
stages : — 

i. Before primary rupture or abortion ; ii. At the time of primary 
rupture or abortion ; iii. From primary rupture to term ; iv. After 
term. 

Before proceeding to discuss the signs which occur during each of 
these stages, it is necessary to point out that the patient is some- 
times aware that she is pregnant. In many cases, however, she is not 
aware of the fact, and the practitioner is often deceived by the absence 
of the usual signs of gestation, such as fulness of the breasts and 
amenorrhoea.. The breast signs are very variable in tubal gestation. 
In many cases they are absent even when the pregnancy has gone on to 
the fifth month ; in others the signs of pregnancy are as clear and as 
marked as in normal gestation. In one of my cases milk was present in 
one breast only, and that was on the same side as the gravid tube. 
Speaking generally, the absence of the usual signs of pregnancy do not 
negative the existence of tubal gestation ; on the other hand their pres- 
ence is valuable, and may lead to a correct diagnosis. 

i. before Primary Rupture. — Gravid tubes have in many instances 
been removed before primary rupture or abortion ; but in nearly all the 
instances recorded before 1891 the operations were undertaken for the 
purpose of removing diseased tubes : on examination of the tubes after 
removal the fact that they were gravid was revealed. Since this date 
the pathology of the early stages of tubal pregnancy has been better 
understood, and a clear distinction recognised between a gravid tube and 
ahsematosalpinx. Many cases have accordingly been published in which 
a correct diagnosis was made before the operation was undertaken. 
This is very gratifying, for it is a matter of the utmost importance to the 
patient, as it spares her the awful peril which attends the rupture of the 
tube. The chief points in this stage are that a woman previously 
regular gives a definite history of a missed menstrual period; soon 
afterwards she suffers from pelvic pain which induces her to seek 
advice ; on examination an enlarged Fallopian tube is detected. If 
there be no history of old tubal disease, or any fact in the history of 
the patient suggesting septic endometritis or gonorrhoea, then the pre- 
sumption is in favour of a gravid tube. 

ii. Primary Rupture. — In tubal gestation the sac ruptures or abor- 
tion occurs at some time before the twelfth week. The effect upon 
the patient depends upon the seat of rupture. When the rupture 
takes place between the layers of the mesometrium the symptoms will, 
as a rule, be less severe than when the tube bursts into the peritoneum. 
The pressure exercised by the blood extravasated into the tissues of 
the mesometrium tends to check haemorrhage, whereas the coelom will 
hold all the blood the patient possesses, and yet produce no haemostatic 
effect by pressure. 

The signs of intraperitoneal rupture are those characteristic of 
internal haemorrhage. The patient complains of a sudden feeling as if 



474 SYSTEM OF GYNECOLOGY 

''' something had given way," and this is followed by general pallor and 
faintness ; the voice is reduced to a faint whisper ; the respiration is 
sighing; the temperature depressed; the pulse rapid and feeble; and 
vomiting usually sets in. In some cases death ensues in a few hours. 

Should the patient recover from the shock, she will sometimes state 
that she suspected herself to be pregnant. The symptoms of rupture 
are often accompanied by haemorrhage from the vagina ; and shreds of 
decidua are passed, so that the case in many points resembles early 
uterine abortion, and is occasionally mistaken for it. Error in such 
circumstances may be avoided by examining the shreds discharged from 
the uterus ; if they are found to be chorionic villi the pregnancy is clearly 
uterine. This simple test has been useful to me on several occasions. 

The rapidity with which the rupture of a gravid tube will sometimes 
destroy life has caused more than one writer to describe this accident "as 
one of the most dreadful calamities to which women can be subjected." 
Indeed, it may be so rapidly fatal that in many recorded cases death was 
attributed to poisoning, until dissection, instituted in many instances by 
the coroner, revealed the true cause of death. In 1880 a well-known 
English actress was taking an ice at a cafe in the Bois de Boulogne when 
she suddenly died. Poisoning was suspected, and the corpse was sent to 
the morgue. At the autopsy the stomach and digestive organs were 
examined for poison. No traces of poison were found, but a gravid tube 
which had burst. 

An analysis of many careful records, and the inspection of specimens 
of gravid tubes, demonstrate that the most dangerous cases are those in 
which the embryo or mole is lodged in the uterine or inner third of the 
tube. Death sometimes follows rupture in three or four hours. 

In some of the recorded cases rupture occurred soon after the patient 
had retired to bed. On inquiry in one case I ascertained that sexual 
congress determined the rupture of the gestation sac. 

It is important to bear in mind that the severe disturbance which is 
usually set up by primary intraperitoneal rupture of a gravid tube is 
simulated by lesions of other abdominal viscera; for example, by per- 
forating ulcer of the stomach, duodenum, small intestine, or vermiform 
appendix ; rupture of a pyosalpinx ; acute axial rotation of an ovarian 
tumour ; acute intestinal obstruction ; renal colic, and biliary colic when 
unaccompanied by jaundice. 

On the other hand, the profound shock which usually accompanies 
the bursting of a gravid tube has been confounded with each of the 
above-mentioned lesions. Malherbe reported the details of a case in 
which a woman thirty-four years of age was submitted to operation for 
supposed strangulated inguinal hernia. On opening the sac it was 
found filled with blood ; the parietes were freely incised, and a gravid 
tube which had burst was found and removed. 

iii. From Primary Rupture to Term. — Erom the third month onwards 
the leading signs of tubal gestation may be summarised thus : — 

(a) Amenorrhoea is occasionally found; frequently there is hsemor- 



EXTRA-UTERINE GESTATION 475 

rhage from the uterus, occurring at irregular intervals, accompanied by 
the escape of decidual membrane : this is a valuable diagnostic sign 
when associated with the physical signs of a tumour outside the uterus. 
It is even more valuable if the patient have missed one or two periods. 
(6) There may or may not be milk in the breasts. Its presence is 
a valuable indication. From its absence nothing to the point can be 
inferred. 

(c) The uterus is slightly enlarged ; the os is usually soft, as in nor- 
mal pregnancy, and patulous. 

(d) A large and gradually increasing swelling exists to one side and 
behind the uterus. Occasionally the foetal heart can be heard, and in 
advanced cases the outlines of the foetus may be distinguished. 

(e) When a woman in whom the existence of tubal gestation is 
suspected is suddenly seized with collapse and all the signs of internal 
bleeding, it is indicative of rupture of the gestation sac. 

(/) Tubal pregnancy is very apt to occur after long intervals of 
sterility. 

iv. After Term. — In spite of all the risks that beset the life of a 
tubal foetus and that of its mother, the pregnancy may go to term. 
Then a remarkable series of events ensues. 

(a) Paroxysmal abdominal pains come on, resembling those of 
natural labour, accompanied by a discharge of blood and mucus from 
the uterus resembling the " show," and the os uteri dilates. 

(h) This unavailing labour may last a few hours or days (it is 
stated to have lasted for weeks in some patients), and then subside. 

(c) The mammae may continue to secrete milk for several weeks. 

These signs sometimes pass away, the amniotic fluid is absorbed, the 
swelling diminishes in size, and the retained foetus causes no trouble. 
In the majority of cases suppuration takes place in the sac, the foetus 
decomposes, and the fragments of its tissues are discharged through 
sinuses in the groin, abdomen, vagina, rectum, or bladder. It should 
be remembered that the onset of labour may rupture the sac. 

In extraperitoneal rupture — that is, when the tube bursts so that the 
blood is extravasated between the layers of the mesometrium — the 
symptoms resemble intraperitoneal rupture, but as a rule are not so 
severe, and the signs of shock pass off quicker. On examining by the 
vagina a rounded, ill-defined swelling will be found on one side of the 
uterus ; when the effused blood is large in amount the uterus ^\i\\ be 
pushed to the opposite side. When the bleeding takes place into the 
left mesometrium it will sometimes extend backwards under the peri- 
toneum, and invade the connective tissue around the rectum ; so that 
when the exploring finger is introduced into the rectum, a semicircle, 
sometimes a ring, of swollen tissue will be felt encircling the gut. 

The escape of decidual membrane from the uterus, accompanied by 
blood, is also an important and fairly constant sign. Occasionally it will 
be necessary to pass a sound into the uterus ; when the tube is gravid 
the cavity of this organ will be found slightly enlarged, and the os is 



476 SYSTEM OF GYNECOLOGY 

invariably patulous. The greatest difficulty in these cases is to be sure 
that the rupture is purely extraperitoneal. In a few cases the rupture 
may involve the peritoneal as well as the mesometric segment of the tube. 

Not infrequently after primary extraperitoneal rupture the symptoms 
of shock pass off, and the embryo continues its development; in many 
instances in which the patients believe themselves pregnant, the haemor- 
rhages from which they suffer, and the signs indicative of the primary 
rupture, may cause but temporary inconvenience. As the embryo grows 
the abdomen increases in size, but the enlargement differs from ordinary 
uterine gestation in that it is lateral instead of median. 

The Differential Diagnosis of Tubal Pregnancy. — The diagnosis of 
tubal pregnancy is nearly always beset with anxiety, which becomes 
intensified when complications exist. For instance : — 

i. Uterine and tubal pregnancy are sometimes concurrent. ii. 
Uterine pregnancy sometimes follows the tubal variety, iii. Tubal 
pregnancy may be bilateral, iv. Tubal pregnancy may be repeated. 
V. Tubal pregnancy and ovarian or parovarian tumours may co-exist. 

It is important to bear in mind that tubal pregnancy may be simu- 
lated by a variety of conditions : — 

(a) Uterine pregnancy. (6) Pregnancy in a bicorned uterus, (c) 
Retroversion of a gravid uterus, (c?) Spurious pregnancy, (e) Ovarian 
tumours. (/) Uterine tumours, {g) Mesometric tumours. i]i) Faeces 
in the rectum. 

Concurrent Uterine and Tubal Pregnancy. — Several examples of 
this combination have been recorded. In 1881 Dr. Galabin described 
an instance of it in a woman thirty-six years of age. 

The history suggested ovarian cyst complicated with pregnancy, 
and that the cyst had ruptured. A combined intra-uterine and extra- 
uterine gestation was regarded as possible. Dr. Galabin performed 
abdominal section. On opening the peritoneum a foetus was discov- 
ered enclosed in its membrane lying to the right side of, above, and 
somewhat behind the uterus. The placenta appeared to be spread out 
very widely, and attached chiefly to the posterior surface of the right 
broad ligament and of the pregnant uterus. The placenta was not dis- 
turbed. Two days later labour pains came on, and the intra-uterine 
child was delivered ; it was dead. The patient continued to lose blood 
from the extra-uterine sac, and died three days after the operation. No 
autopsy was allowed. 

Franklin met with the same combination in a woman, mother of five 
children. The patient was in labour when difficulty was experienced ; 
Caesarean section was performed, and an adventitious mass was found 
in the pelvis : this was found to be an extra-uterine child. Death fol- 
lowed in half an hour. Similar cases have been reported by Cooke, 
Sale, and Wilson. 

Other examples have been reported, but these illustrate the leading 
points in the clinical history of this accident. Its gravity is sufficiently 
obvious, for in all the reported cases the patients died within a few days 



EX TRA- UTERINE GES TA TION 



All 



of the operation. The great difficulty in this, as in all other examples 
of advanced extra-uterine gestation, is the excessive risk of haemorrhage 
which follows interference with the placenta. 

Uterine subsequent to Tubal Gestation. — It has been mentioned that 
tubal gestation may go to term, spurious labour supervene, and the 
foetus become sequestrated in the mesometrium : on this grave accident 
uterine pregnancy may supervene, — a combination, fortunately for 
mothers, very rare. 

Stonham, whilst conducting an autopsy on a woman forty-three years 
of age, who died in the seventh month of her pregnancy from bronchitis 
and ulceration of the trachea, found a foetus (enclosed in a thick membrane) 
in the right mesometrium. Some of the bones were completely macerated ; 
the soft structures were soapy in consistence. There w^as a thin deposit 
of calcareous material on the inner wall of the cyst. The left meso- 
metrium was normal. The uterus contained a seven months' foetus, which 
was apparently living at the mother's death since it showed no signs of 
maceration. Worrall of Sydney published details of a case in which a 
woman with a foetus in the mesometrium subsequently conceived in the 
uterus. The nature of the case was correctly diagnosed, and an opera- 
tion for the relief of the condition was successfully carried out. 

The patient w^as thirty years of age, and mother of five children. 
In April 1888, the menses having been absent six weeks, she was seized 
in the night with severe abdominal pains, faintness, and vomiting. She 
was confined to her bed six weeks. In October of the same year, at about 
the eighth month of gestation, a sudden flooding, unaccompanied by pain, 
came on, and lasted three days. A month later she was seized with 
severe abdominal pains, which lasted a fortnight ; she then began to 
decrease in size, and menstruation reappeared. The tumour decreased 
to a certain point, and then remained stationary. After July 1889 she 
ceased to menstruate, and her abdomen gradually enlarged. A few months 
later Dr. Worrall was consulted, and he correctly diagnosed the existence 
of a living intra-uterine foetus and an extra-uterine foetus which had been 
dead about two years. Acting on this diagnosis, he removed the extra- 
uterine foetus from the left mesometrium. It was not decomposed, but 
was very flaccid, and weighed 4^ lbs. The placenta was left, and the 
sac drained. Next day labour came on, and the intra-uterine child w^as 
born. It was a female, and cried feebly, " but, in spite of every care,. 
died in a few hours." The patient made a good recovery. 

Bozeman has recorded a case in which uterine supervened on extra- 
uterine gestation. After delivery of the intra-uterine foetus an uneven 
and projecting mass presented in the recto-vaginal fossa. This proved to» 
be the sac of an extra-uterine pregnancy. From the history of the case- 
it had probably been dead between three and four years. The contents 
of the sac were evacuated through the vagina. The patient recovered. 

Bilateral (Concurrent) Tubal Pregnancy. — Several suspected exam- 
ples of this rare condition have been recorded, but in many the evidence 
was not absolute. In 1892 Dr. W. Walter sent me two Fallopian tubes 



478 SYSTEM OF GYNECOLOGY 

which lie had removed from a woman twenty-nine years of age. The 
left contained an embryo and placenta ; the walls of the gestation sac 
had burst and caused severe bleeding, which led to operation. The 
right tube contained a typical tubal mole. This, so far as I know, is 
the first indisputable example of pregnancy occurring concurrently in 
both Fallopian tubes of the same individual. 

Repeated Tubal Pregnancy. — Under this heading it is usual to place 
those cases, fortunately rare, in which women have conceived in one 
tube and have been submitted to operation ; and that subsequently the 
remaining tube became gravid. 

Dr. Herman has recorded an example of this condition. In January 
1887, he removed from a woman twenty-eight years of age a gravid right 
Fallopian tube which had burst into the peritoneal cavity. In May 1890 
the patient again came under observation for pelvic trouble, and Herman 
came to the conclusion that the woman was again the victim of tubal 
pregnancy. Abdominal section was performed and the left Fallopian 
tube was removed. It contained a tubal mole. 

Mr. Lawson Tait, in 1885, operated on a woman twenty-five years of 
age, and removed a gestation sac with the foetus and placenta from the 
right side of the pelvis. This woman recovered, and eighteen months 
later was confined of a child at term. Fifteen months after delivery 
she again became pregnant, and when, according to her computation, 
the pregnancy had advanced to the fourth month she was seized with 
a severe abdominal pain and died in five hours. At the autopsy a tubo- 
uterine gestation was found on the left side. 

Mackenrodt reported the case of a woman thirty-two years of age 
who was seized in May 1890 with signs indicating rupture of a gravid 
tube. These signs were repeated in October 1891. The abdomen was 
opened, and a gestation sac the size of a large Q%g removed from the left 
side. On the opposite side a second sac was found containing foetal bones. 

Twin Tubal Pregnancy. — A few writers on extra-uterine pregnancy, 
Parry especially, deal with the subject of twins in tubal pregnancy as 
if it were a common event. A critical study of Parry's writings shows 
clearly enough that he confounded three distinct conditions : — 

i. Concurrent tubal and uterine gestation, ii. Uterine subsequent 
to tubal pregnancy, iii. Twin gestation in a Fallopian tube. 

An example of tubal twins has yet to be recorded. 

Tubal Pregnancy and Ovarian Tumours sometimes co-exist. — Several 
instances have been recorded in which ovarian or parovarian cysts have 
co-existed with a gravid tube. In some cases a parovarian cyst has 
existed on the same side as the pregnant tube, and may perhaps have 
determined the accident. In a case under my own care an ovarian cyst 
as large as a cocoa-nut existed on the right side and a gravid tube (which 
had aborted) on the left. 

It is rarely that an ovarian tumour co-existing with uterine pregnancy 
simulates combined tubal and uterine pregnancy. In 1891 Dr. Griffith 
communicated to the Obstetrical Society details of a case in which a 



EXTRA-UTERINE GESTATION 479 

woman in labour came under his care. She was supposed to have twins, 
one intra-uterine and the other extra-uterine. It ultimately turned out 
that the patient was pregnant, and what was supposed to be the head 
of an extra-uterine child was a large fibroma of the ovary obstructing 
labour. She died, and the pelvis with the organ and tumour in position 
was bisected ; one-half of the specimen is preserved in the museum of 
the Koyal College of Surgeons, the other in that of St. Bartholomew's 
Hospital, London. 

Normal Pregnancy. — This has been mistaken for tubal pregnancy. 
The abdomen has been opened, the foetus extracted, and the uterus 
amputated before the error was discovered. 

Pregnancy in one Horn of a Bicorned Uterus. — A few cases are known 
in which this anomaly has led to grave difficulty in diagnosis and to error 
in treatment. Pregnancy in the ill-developed horn of the so-called 
''unicorn" uterus requires the same treatment as tubal pregnancy. 

Abnormal Thinness of the Walls of a Gravid Uterus. — Lawson Tait 
has drawn attention to some cases which have fallen under his notice 
in which the walls of the uterus were of such extreme thinness that the 
foetus could be easily felt. And in reference to one case he Avrites, 
" The oliild could be felt with the most astonishing distinctness, and it 
floated about as if it were perfectly free in the abdomen." There is 
also a reference to a similar condition in Parry's well-known work. 
That this is a condition to bear in mind the following case, furnished 
me by a surgeon, well illustrates : — 

A woman, twenty-nine years of age, was admitted into the infirmary in 
such an aneemic and emaciated condition that she was too weak to stand. 
There was vomiting, amenorrhoea of six months' standing, pigmentation 
along the linea alba, and milk in the breasts. The belly was distended, 
and in the right iliac fossa was lodged a crescentic mass not unlike a 
foetus in outline, and so mobile that it could be pushed into the right 
iliac fossa. The remarkable ease with which this body could be grasped, 
and its position when at rest, led to the diagnosis of extra-uterine preg- 
nancy, and an operation decided upon. On incising the peritoneum a 
smooth glistening body of a pearly gray colour, exactly like an ovarian 
cyst, was seen, but it had the shape and occupied the position of the 
uterus. The foetus could be felt and pushed about in the fluid witli 
ease. The wound was at once closed. Miscarriage took place on the 
third day. The woman recovered. 

In such cases, when the diagnosis is so doubtful, before resorting to 
operation the employment of a uterine sound would easily determine 
the nature of the case. 

Retroversion of the gravid uterus has been a source of error. Eeten- 
sion of urine, so characteristic of this condition, is occasionally produced 
when the embryo occupies the mesometrium, accompanied by much 
haemorrhage. On the other hand extra-uterine gestation has been mis- 
taken for retroversion of a gravid uterus. Dr. Godson relates a case 
which occurred in a woman who had been married thirteen years. A 



48o SYSTEM OF GYNECOLOGY 

year after marriage she had one child. She remained sterile for twelve 
years, and then became pregnant. On account of inability to pass water 
she was admitted into St. Bartholomew's Hospital, and an ineffectual 
attempt made to replace the uterus. Eventually Dr. Carter removed 
an extra-uterine foetus by abdominal section. 

Spurious Pregnancy. — It is well known that in several instances the 
abdomen has been opened under the impression that the patients were 
suffering from tubal pregnancy, but nothing abnormal found. 

Dr. Sinclair Stevenson reported a case of spurious pregnancy simulat- 
ing ectopic gestation of the fourth month in which there was amenorrhoea. 
So strongly marked were the signs of tubal pregnancy that the abdomen 
was .opened ; instead of pregnancy a small cyst of the ovary was found. 

Lastly, the difficulties which sometimes beset the differential diagnosis 
of pelvic swellings is shown by the fact that in very many instances 
abdominal section has been undertaken to remove supposed ovarian 
tumours, dilated tubes, and the like, which turned out to be gestation 
sacs. This is no reflection on the surgeon, and the interference is more 
than justified. 

Mr. Skene Keith has briefly mentioned a case in which his father 
performed abdominal section, expecting to find a " fibroid tumour " ; 
but on cutting into it, a foetus was found which had been dead nearly 
two years. 

Mr. Knowsley Thornton and others have dissected out gestation 
sacs under the belief that they were dealing with tumours. 

On the other hand, operations have been undertaken under the 
impression that the patients were victims to advanced extra-uterine 
pregnancy ; but tumours and even a mass of faeces in the rectum have 
been found instead. 

Sir John Williams writes : " I once saw a swelling, which appeared 
to be a small ovarian cyst, aspirated. It proved afterwards to be the 
placenta in a case of extra-uterine gestation." 

One of the gravest errors is to mistake a tubal pregnancy in its 
mesometric stage for a sarcoma or myoma when the parts have been 
exposed by abdominal section. This is a serious error, as the operator, 
instead of opening the sac, attempts to remove the tumour, usually with 
a fatal result. 

The Treatment of Tubal Gestation. — The admirable results which 
have followed the treatment of tubal pregnancy by abdominal section 
have served to establish this method on as secure a footing as ovariotomy. 

Methods formerly advocated, such as killing the foetus by injecting 
drugs into its body, or, more recently, by electricity and similar un- 
surgical procedures, are of such an unsatisfactory character that they 
will not be considered. 

The risks and difficulties of an operation for tubal pregnancy depend 
mainly upon the extent to which gestation has advanced at the time the 
operation is performed. The operative treatment may be considered 
in the following stages : — 



EXTRA-UTERINE GESTATION 481 

i. Before primary rupture or abortion, ii. At tlie time of primary 
rupture, iii. Subsequent to rupture, iv. When the embryo and placenta 
occupy the mesometrium. The fourth stage must be considered in sec- 
tions, thus : (a) At or near term, the chikl being alive. (6) At, near, or 
after term, the child being dead, mummified, or reduced to a litliopoedion. 
(c) After decomposition of the foetus and suppuration in the sac. 

i. Before Primary Rupture or Abortion. — Opportunities of dealing 
with cases in this stage are uncommon, as gravid tubes rarely cause 
trouble before they rupture or abort. When the evidence is convincing, 
cceliotomy should be performed without delay. 

ii. At the Time of Primary Rupture or Abortion. — The majority of 
cases of tubal pregnancy come under observation at the time of primary 
rupture or abortion, and this is usually some period between the fourth 
and twelfth week. 

When the symptoms of haemorrhage are unmistakable and the 
patient's life in grave danger, cceliotomy should be performed without 
delay, unless there be good evidence that the rupture is extraperitoneal. 
The employment of this method is in strict accordance with the canon 
of surgery, valid in other regions of the body, namely, to arrest haemor- 
rhage at the earliest possible moment. 

There are few accidents that test the skill, nerve, and resource of a 
surgeon more than cceliotomy for a suspected intraperitoneal rupture of 
a gravid tube, and few operations are followed by such brilliant results. 

The method of performing the operation before and at the time of 
primary rupture is identical with oophorectomy. 

Occasionally the rent in the tube may extend to the fundus of the 
uterus, especially if the embryo be lodged near the uterus. Such rents 
should be carefully sutured with cat-gut ; occasionally it will be necessary 
to use silk to control the bleeding. 

iii. After Primary Rupture. — Cases are submitted to operation at 
periods varying from a few days to weeks or even months after the tube 
has ruptured. It has been already pointed out that in an exceedingly 
large proportion of these cases the tube is occupied by a mole. 

When the tube bursts the haemorrhage may not be so profuse as to 
induce death, and the patient, recovering from the shock, may not mani- 
fest such grave symptoms as to make surgical aid obviously necessary. 
The consequence is that the patient remains for several weeks under 
palliative treatment (unless a renewal of bleeding killed her). At last 
surgical aid is sought, and a discovery of the true nature of the case 
leads to cceliotomy. 

In such cases, when the abdomen is opened, the free blood is easily 
washed out by a stream of warm water. The damaged tube and ovary 
are removed as in oophorectomy. When much free blood exists in the 
peritoneal cavity care must be taken that no clots are allowed to remain 
in the iliac fossae. When blood has remained in the peritoneal cavity 
for several weeks after rupture it is invariably necessary to drain. 

The cases in which abortion or rupture of gravid tubes gives rise to 

2i 



482 SYSTEM OF GYNECOLOGY 

intraperitoneal bleeding moderate in amount, and insufficient to give rise 
to symptoms which directly threaten life, are those in which the effused 
blood eventually becomes shut off from the general peritoneal cavity by 
adhesions of intestines and omentum, as explained in the section dealing 
with primary intraperitoneal rupture (p. 462). 

Experience has not yet decided whether it is safer for the patient 
under such conditions to run the risks of immediate operation or to wait 
for a few weeks in order to ascertain if absorption will occur. At pres- 
ent I believe the patient's interests are best served by allowing her to 
recover from the immediate shock, and then dealing with the damaged 
tube by coeliotomy. 

iv. Mesometric Gestation. — When the tube bursts between the layers 
of the mesometrium operative interference is rarely called for. In a small 
proportion of cases the embryo survives the accident and continues to 
grow ; and at any date from this period, up to term, surgical interference 
may be called for to save the patient from the disastrous effects of sec- 
ondary rapture into the coelom. 

When gestation has not advanced beyond the fourth month, it is 
possible to remove the embryo, tube, ovary, and adjacent portion of the 
mesometrium with the placenta, and thoroughly to remove all blood-clot. 

When gestation has advanced beyond the fourth month the placenta 
has become too large to be dealt with in this summary manner ; at the 
same time, the sac has encroached upon the peritoneum belonging to 
adjacent organs, such as the uterus and rectum, the bladder, and not 
infrequently the anterior wall of the abdomen. 

After the fifth month operative measures for tubal gestation must 
be considered under two headings : — (a) The treatment of the sac ; (b) 
The treatment of the placenta. 

(a) The Treatment of the Sac. — The gestation sac in the last stages 
of tubal pregnancy consists of the remnants of the expanded tube and 
the mesometrium, which may be thickened in some parts and expanded 
in others. Coils of intestine and omentum usually adhere to the walls 
of the sac. The removal of such a sac is fraught with considerable risk, 
not only to the adjacent large blood-vessels, but to the viscera and ureters. 
Nevertheless, in spite of the great risk of the proceeding, it has on one 
occasion been successfully accomplished, and the patient luckily recovered. 
It will generally be found that in cases where attempts have been made 
to dissect out the sac, the operation was begun under the impression 
that the abnormal mass was a tumour. 

Experience has decided clearly enough that the safest plan is to incise 
the sac, remove the foetus, and stitch the edges of the sac to the abdom- 
inal wound; precisely as in the plan recommended after enucleating 
large cysts and tumours from between the layers of the mesometrium. 

In those cases where the gestation has well advanced, the peritoneum 
may be so removed from the anterior abdominal wall that the sac can 
be penetrated without intentionally opening the peritoneal cavity at any 
stage of the operation. 



EXTRA-UTERINE GESTATION 483 

(5) The chief difficulty which perplexes the operator is how to deal with 
the placenta. There can be no doubt that the situation of the placenta 
largely influences the result, and so far as I can judge from the reports of 
cases, as well as from my own experience, the most promising cases are 
those in which the placenta is situated in the pelvis below the foetus. 
When the placenta is situated above the foetus it will, in many cases, be 
incised as the sac is opened, and give rise to such furious bleeding that 
in several cases the patient has succumbed to the haemorrhage. Even 
prompt seizure and ligature of the pedicle on the uterine side of the sac 
fail to arrest the bleeding ; in such a case the abdominal aorta must be 
compressed; and such methods as packing with sponges and the applica- 
tion of perchloride or persulphate of iron to the bleeding surfaces have 
been adopted, in a few instances with success. 

The fear of such hsemorrhage and its uncontrollable character have 
induced several surgeons to adopt the alternative plan of leaving the 
placenta, and allowing it to slough away gradually, taking care, of course, 
to keep up a free communication with the exterior. The disadvantages of 
this method are many. The process of suppuration and discharge of the 
placenta is long and dangerous on account of the great risk the patient 
runs of septicaemia and peritonitis ; in a large proportion of cases a faecal 
fistula forms ; in the majority of cases, however, such fistulas gradually 
close as the patient convalesces. 

In order to avoid this risk attempts have been made, after removing 
the foetus, to irrigate the gestation sac, and to tie the cord thoroughly close 
to the placenta without disturbing the latter ; the cavity must be 
cautiously sponged and then hermetically closed, in the hope that the 
placenta will atrophy. Unfortunately for this method there is another 
source of infection to reckon with. It has already been mentioned that, 
as the gestation sac enlarges, it frequently strips the peritoneum from the 
rectum, and thus the placenta itself may acquire adhesions to the bowels. 
The result is that intestinal micro-organisms gain access to the placenta 
and set up decomposition. 

With our present experience the rules for the treatment of the 
placenta may be formulated thus : — i. When the placenta is situated 
above the foetus it is good practice to attempt its removal, ii. In 
some instances the placenta becomes detached in the course of the opera- 
tion, and leaves no choice, iii. When the placenta is below the foetus it 
may be left. iv. Should the placenta be left, and the sac closed, and there- 
after symptoms of suppuration occur, then the wound must be reopened 
and the placenta removed, v. If the foetus die before the operation is 
attempted the placenta can be removed without risk of haemorrhage. 

Could we feel sure that the placenta would not decompose, the best 
method would be to close the sac hermetically, and leave the placenta to 
atrophy ; or to wait until we know that the placental circulation had ceased, 
then reopen the sac and take out the placenta. Unfortunately, we have 
no precise data to guide us in this respect, and whilst waiting for the 
placenta to die, its tissues decompose. 



484 SYSTEM OF GYNECOLOGY 

Apprehension that the placenta may grow after the foetus has been 
removed is absolutely groundless ; there is positive evidence that, if it 
does not decompose, it quietly and completely atrophies. This is further 
proved by the absence of placenta, when the foetus is in the state of 
lithopaedion. 

The great risk of violent haemorrhage renders an operation for tubal 
pregnancy with a quick placenta between the fifth and ninth months of 
gestation the most dangerous in the whole range of surgery ; hence it 
cannot be urged with too much force that as soon as it is fairly evident 
that a woman has a tubal pregnancy, it should be dealt with by operation 
without delay. 

It has been urged that if, after primary rupture, there is evidence 
that the child is developing, operative interference should be deferred 
until the seventh month, unless urgent symptoms arise, as there may be 
a prospect of saving the child's life. To my mind this is an objection- 
able practice, for the following reasons : — i. Extra-uterine children are 
puny, ill-developed and, in a large proportion of cases, malformed, ii. 
They rarely survive extraction many weeks, or many months at most, 
iii. In endeavouring to save the life of a defective child the more valuable 
life of the mother is frequently sacrificed. It is, of course, conceivable 
that in some cases the life of the child may be of great importance. 

After Death of the Foetus at or near Term. — Operations after the death 
of the foetus are less complicated than when it is alive and the placental 
circulation in full vigour. Not only is the proceeding simplified from the 
operative point of view, but the results, in so far as the mother is con- 
cerned, are also much more satisfactory. 

When the operation is undertaken in cases where the foetus is in the 
state of lithopcedion the procedure is very simple, because the placenta has 
completely disappeared. There is a circumstance in connection with a 
foetus wholly or partially converted into adipocere which is of some impor- 
tance to the surgeon, namely, that its tissues have a strong tendency to 
adhere to the walls of the sac. 

After Decomj)osition of the Foetus and Suppuration of the Sac. — After 
death and decomposition of the foetus fistulas form, by which pus, accom- 
panied by fragments of foetal tissue and bones, finds an exit — either 
through the rectum, vagina, bladder, uterus, or at some spot in the anterior 
abdominal wall below the umbilicus. The treatment in such cases is sim- 
plicity itself. The sinuses should be dilated, and all fragments removed 
from the cavity in which they lie. When this is done thoroughly, the si- 
nuses will rapidly granulate and close. Partial operations are useless ; if 
but a bit of a bone be allowed to remain, a troublesome fistula will persist. 

John Bland Sutton. 

The works of greatest value on the subject of extra-uterine gestation in the English 
language are the following : — 

Campbell, William. Memoir on Extra-Uterine Gestation. Edinburgh, 1840. 
This brochure is useful, as it reveals the slender and unreliable character of the 



PELVIC INFLAMMATION 485 

evidence on which the varieties of extra-uterine gestation were based in the early 
part of this century. 

Parry, John S. Extra-Uterine Pregnancy : its Causes, Species, Pathological 
Anatomy, Clinical History, Diagnosis, Prognosis, and Treatment. London, 1876. 
This -work is a great improvement on that of Campbell ; but like that book, its great 
defect is the admission, uncriticised, of every reported case as evidence of the existence 
of the speculative varieties of extra-uterine gestation according to the fancy of the 
reporter. 

Tait, Lawson. Ectopic Gestation, 1888. This epoch-making brochure is A^aluable 
only for the great advance it marks in the surgery of tubal gestation, but for the 
admirable generalisation enunciated by its author that X)rohahly all forms of ectopic 
pregnancy have their starting-point in the Fallopian tubes. This generalisation, sub- 
sequently put on an anatomical basis by other workers, has served more than any- 
thing else to revolutionise the pathology and surgery of what was formerly termed 
" pelvic haematocele." 

REFERENCES 

1. Barnes. Trans. Obstet. Soc. vol. xxiii. p. 170. — 2. Berry Hart and Carter, 
note Edinburgh Medical Journal, vol. xxxiii. 322. — 3. Bozeman. Hew York Med. 
Journal, 1884, vol. xi. p. (i93. — 4. Champxeys. Trans. Obstet. Soc. vol. xix. p. 
456. — 5. Cheston. Medico-Chir. Trans, vol. v. p. 104. — 6. Dezeimeris. Journal 
de Connaissances, Medico-Chirurgicales, 1836. Reprinted and translated by Berry 
Hart in Obstet. Trans. Edin. vol. xviii. p. 233, and Am. Jour, of Obstetrics, vol. xxix. 
p. 577.-7. Franklin. Brit. Med. Journal, 1894, vol, i. p. 1019. —8. Galabin. 
Tra7is. Obstet. Soc. vol. xiii. p. 821. — 9. Godson. Pj-oc. Med. Soc. London, vol. vii. p. 
390. — 10. Herman. Brit. Med. Journal, 1890, vol. ii. p. 722.-11. Jessop. Titans. 
Obstet. Soc. vol. xviii. p. 261. — 12. Keith, Skene. Obstet. Trans. Edin. vol. x. p. 92. — 
13. jMalherbe. Bull, de la Soc. Anat. de Paris, t. ix. p. 3. — 14. Stevenson, Sinclair. 
Trans. Obstet. Soc. vol. xxxii. p. 216. — 15. Stonham. Trans. Path. Soc. vol. xxxviii. 
p. 445.-16. Taylor. Trans. Obstet. Soc. vol. xxxiii. p. 115.-17. Tilt. Trans. 
Obstet. Soc. 1873, vol. xv. p. 155. — IS. "Worrall. Med. Press and Circular, 1891, vol. 
1. p. 296.-19. Walter. Bt^it. Med. Journal, 1892, vol. ii. p. 732.-20. Webster, 
Clarence. Ectopic Pregnancy, IS^b. — 21. Williams, Sir John. Trans. Obstet. Soc. 
vol. xxix. p. 490. 

J. B. S. 



PELVIC INFLAMMATION" 

In dealing with, so wide a subject as pelvic inflammation it is necessary 
at the outset to state the precise meaning which, so far as the present 
article is concerned, those Avords are intended to convey. The phrase, 
as here used, must be understood to include the two affections known 
as pelvic cellulitis and pelvic peritonitis. The inflammation of the several 
viscera contained in the female pelvis will be described in other parts 
of this work, and will only be referred to here in so far as they are 
concerned in the pathological processes that lead to the two diseases 
just named. 

Several writers of distinction, amongst Avhom Virchow and Matthews 
Duncan may be specially mentioned, have named the inflammations now 
about to be considered " perimetritis " and '•parametritis " : the former 
name was used by them to signify inflammation of the pelvic peritoneum ; 



486 SYSTEM OF GYNECOLOGY 

the latter to signify inflammatioii of the pelvic connective tissue. These 
terms have not been adopted in the following article, for several reasons 
of which only two or three need be given. Firstly, the words perime- 
tritis and parametritis are so nearly alike that their use may introduce 
an additional and quite unnecessary element of confusion into a subject 
that, for the beginner at any rate, is already sufficiently beset with dif- 
ficulties : secondly, these terms imply a difference in the anatomical 
relations of the peritoneum and of the connective tissue to the uterus 
which does not really exist; the pelvic connective tissue and pelvic 
peritoneum are in equally close contact with the uterus. It is inaccurate 
and misleading, therefore, to speak of an inflammation of the one tissue 
as being an inflammation around the uterus, and an inflammation of the 
other as being an inflammation near it. Thirdly, the words perimetritis 
and parametritis describe, in terms of the uterus alone, affections which 
often involve all parts of the pelvis, and are not necessarily uterine even 
in their origin. 

Until recent years the views generally held and taught with reference 
to pelvicinflammationwere exceedingly vague and unsatisfactory; inmany 
respects indeed erroneous. Clinical observation \vas so seldom brought 
to the test of the operating theatre and the post-mortem room that certain 
erroneous inferences drawn from facts observed at the bedside remained 
year after year uncorrected by actual inspection and dissection, and were 
thus accepted as articles of current professional belief. Almost every 
attack of pelvic inflammation was believed to be a cellulitis ; and if, on 
vaginal examination, a hard, irregular, fixed mass could be felt on one 
or both sides of the uterus, the diagnosis of cellulitis was held to be 
established beyond cavil. It is true that many years ago Aran and 
Bernutz, in France, combated this view, and the latter proved by a 
large mass of post-mortem evidence the true nature of the majority of 
these swellings : but the influence of their writings upon the current 
belief and teaching was for many years inappreciable. It was not, 
indeed, until the practice of abdominal surgery became extended, and 
opportunities of comparing the physical signs with the actual conditions 
became thereby more frequent, that the truth of their main contention 
began to be generally recognised and accepted. The knowledge thus 
gained from abdominal surgery on the one hand, and the advances made 
in our knowledge of the anatomy of the female pelvis — especially by 
the study of frozen sections — on the other, have completely revolu- 
tionised our views of pelvic inflammation ; and the light shed by modern 
research on the inflammatory process itself has tended still further in the 
same direction. Whosoever now undertakes to give an account of pelvic 
inflammation must consider it from an entirely new stand-point, both as 
regards its etiology, its pathology, its diagnosis, and its treatment. It 
is not pretended that our knowledge is as yet sufficiently complete to 
make it possible to deal with any of these points in an entirely satisfactory 
manner. All we can attempt at present is to indicate the lines on which 
the subject must be studied henceforth, and to eliminate from the descrip- 



PELVIC INFLAMMATION 487 

tion all that modern investigation has shown to be ill-founded or 
erroneous. 

After these introductory remarks on the general subject of pelvic 
inflammation, we may proceed to consider its two great varieties. 

Pelvic Cellulitis 
(Synonyms. — Parametritis ; Periuterine phlegmon) 

Definition. — Pelvic cellulitis is an inflammation of the pelvic connec- 
tive tissue. Such an inflammation may be primary or secondary; that is, 
it may originate in the connective tissue itself, or it may originate in one 
of the neighbouring structures and reach the connective tissue by exten- 
sion. The primary form, which is the one here considered, is an acute 
infective disease ; indeed, it differs in no respect from acute inflammation 
of the connective tissue in any other part of the body. Chronic pelvic 
cellulitis is always a secondary afl'ection, complicating inflammation of 
some other part; it is never the sequel of an acute cellulitis. 

Anatomy. — The pelvic connective tissue is not a special structure, 
but is a "portion of a wide system of mesoblastic connective tissue which 
surrounds the great vessels of the trunk, accompanying their branches 
from origin to termination, and extending, mainly in the form of peri- 
vascular sheaths, to all parts of the body " (Anderson and Makins). In 
the pelvis the connective tissue is found partly in the form of a loose 
areolar network, and partly in the more condensed form of fasciae. It 
surrounds all the blood-vessels, nerves, and lymphatics, as well as the 
ureters ; and passes, as investing sheaths, to certain of these outside 
the limits of the pelvic cavity. Below, it is shut off from the perineum 
and ischio-rectal fossae by the pelvic fascia. "This strong aponeurosis is 
attached to the pelvic wall between the pubic bones and bodies of the 
ischia, along that thickening of the obturator fascia known as the white 
line. From this it passes as a continuous sheet over the levator ani and 
coccygeus muscles to the vagina in front, and the rectum and coccyx 
behind. Behind the pubic symphysis it is closely blended with the 
vaginal orifice under the name of the triangular ligament. All inflam- 
matory exudation connected with the female genitals above the vulva 
takes place above this strong fascia " (Keiller). The cellular area of the 
pelvis, thus bounded below, has for its upper boundary the peritoneum. 
Here, however, its limitation is less strict, as it is continuous with the 
subserous connective tissue of the parietal peritoneum of the abdominal 
cavity. Turning now to the distribution of the pelvic connective tissue 
we find that, except perhaps over the fundus uteri, it forms a layer 
under the entire pelvic peritoneum, parietal and visceral. The so-called 
" ligaments " of the uterus contain a greater or less quantity of it between 
the peritoneal folds of which they are composed : and in certain special 
situations it may be said to be abundant ; for example, around the supra- 
vaginal portion of the cervix uteri, along the base of the broad ligaments. 



488 SYSTEM OF GYNECOLOGY 

and between the bladder and the symphysis pubis. In the last-named 
situation it contains in its meshes a varying quantity of fat. 

The ofB-ce of the connective tissue, in the pelvis as elsewhere, is simply 
" to connect and support the other tissues, performing thus a passive 
mechanical function" (Schafer). 

The layer of the connective tissue intervening between the vaginal 
roof and the peritoneum does not ordinarily measure more than about 
one-third of an inch in thickness ; but the study of frozen sections has 
shown us that in pregnancy its thickness is greatly increased. The broad 
ligaments are gradually drawn upwards during the growth and develop- 
ment of the pregnant uterus, until, at the end of pregnancy, they lie in 
the iliac fossae, entirely above the brim of the pelvis ; and no peritoneum 
is found dipping into the lateral parts of the pelvis. The space thus 
vacated by the broad ligaments and the reflections of peritoneum behind 
and in front of them is filled up by connective tissue, so that the 
quantity of connective tissue in the pelvis is in the later months of 
pregnancy enormously increased. This fact, it need scarcely be said, has 
a most important clinical bearing. 

Etiology. — Primary pelvic cellulitis is always a result of septic in- 
fection. Its most common source is the absorption of septic matter 
through the lacerations of the cervix uteri and of the upper part of the 
vagina which occur during labour. Injury to the vagina results from the 
use of obstetric instruments, especially the forceps, much more frequently 
than is generally supposed. On many occasions, when examining cases 
of puerperal pelvic cellulitis seen in consultation, I have discovered 
wounds of the vagina, entirely unsuspected by the medical practitioner 
in attendance, which had evidently been caused by the project- 
ing edge of one of the blades of the forceps. Such wounds, if they 
remain aseptic, readily heal ; but it often happens that septic matter 
finds its way into them, and then pelvic cellulitis results. In rare cases 
cellulitis may commence in the inner portion of the broad ligament im- 
mediately outside the uterus (where the connective tissue of the broad 
ligament is thickest) from direct infection through the tissues of the 
uterine wall. Polk and Lewers have each described a case of this kind, 
verified by post-mortem examination. Other sources of infection are the 
various surgical manipulations practised on the vagina and cervix. Before 
the necessity of aseptic precautions was understood and generally acted 
upon, the most trifling surgical proceedings in these parts were apt to 
be followed by an attack of cellulitis. Cases thus produced are now 
happily rare. Septic infection following abortion seldom gives rise to 
primary pelvic cellulitis, for the simple reason that the cervix uteri and 
vagina are not exposed to injury ; the cervix is not unduly stretched 
during the passage of the ovum, and the vagina is not wounded by 
instruments. 

Inasmuch as lacerations of the cervix and upper part of the vagina 
(the parts around which the connective tissue is found in greatest 
abundance) are the injuries most likely to be followed by cellulitis, it 



PELVIC INFLAMMATION 489 

follows that any surgical operation by which, the integrity of these tissues 
is endangered, such as the removal of large uterine polypi, may, as in the 
process of parturition, open the way for cellulitic infection. It is obvious 
that special danger is incurred if, at the time of their expulsion or removal, 
the polypi are undergoing necrosis. 

In connection with the etiology of cellulitis it must be remembered 
that whenever the connective tissue has been subjected to bruising, as 
in parturition and the expulsion or removal of large polypi, its power of 
resistance to the infective process has been thereby diminished ; or, in 
other words, its susceptibility to infection has been increased. 

The lymphatics are the channels by which the poison is conveyed to the 
connective tissue. Hence there is always a certain amount of lymphan- 
gitis associated with cellulitis. It is highly probable that the lymphatic 
glands also are generally implicated, as well as the lymphatic vessels. 
But as both the lumbar glands, which receive the lymphatics from the 
broad ligaments and the body of the uterus, and the hypogastric or pelvic 
glands which receive the lymphatics from the cervix uteri and upper 
portion of the vagina, are out of reach of the examining finger, we are 
without direct clinical evidence of glandular enlargement. We know, 
however, that in acute cellulitis in other regions of the body, where the 
lymphatic glands are in situations in which they can be examined by the 
sense of touch, glandular enlargement is invariably found and glandular 
suppuration is by no means uncommon. Hence, we are justified by 
analogy in concluding that in pelvic cellulitis a similar condition of things 
usually obtains. Moreover, cases of cellulitic abscess in the pelvis not 
unfrequently occur in which the situation of the abscess makes it highly 
probable that the hypogastric glands are involved in the suppuration. 

Frequency. — It is not possible at present to give any exact state- 
ments as to the frequency of pelvic cellulitis. It can be stated, how- 
ever, with certainty that, compared with pelvic peritonitis, it is a rare 
affection. 

Pathological Anatomy. — Pelvic cellulitis occurs with or without the 
formation of pus. In the latter case, as in cellulitis elsewhere, there 
is an exudation of coagulable lymph, with oedema, into the tissue of the 
infected area, which at first produces increase in bulk without manifest 
alteration of consistence. Very soon, however, the inflamed tissue be- 
comes stiff and indurated ; and at a later stage the hardness is often so 
marked as to be not inappropriately compared with cartilage. As the 
patient recovers, the inflammatory exudation gradually undergoes absorp- 
tion and eventually disappears altogether. When suppuration occurs the 
result is a true pelvic abscess. Usually there is a single large abscess 
cavity ; but occasionally several abscesses are found in contiguous por- 
tions of the cellular area. 

Symptoms. — Pelvic cellulitis is often ushered in by a rigor. In 
puerperal cases this usually occurs on the second or third day after de- 
livery, but it may take place later. In non-puerperal cases the interval 
between the period of infection and the first manifestation of symptoms 



490 SYSTEM OF GYNECOLOGY 

seldom exceeds a day or two. It is the occurrence of this rigor or chill, 
as the initial symptom, that has given rise to the popular but erroneous 
notion that the disease may be the result of exposure to cold. Simul- 
taneously with the rigor, the temperature rises and the pulse becomes 
accelerated. Pain seldom occurs unless the inflammation extend to the 
neighbouring peritoneum. In cases attended with suppuration perhaps 
the most marked symptom is the progressive emaciation : this is always 
associated with pallor and with a certain earthy sallowness of the skin 
which is highly characteristic. The skin over the body generally is harsh 
and dry and covered with branny scales, the result of fine desquamation. 
The patient, in severe cases, looks extremely ill. All desire for food is 
lost. The bowels are ordinarily constipated, though occasionally there is 
diarrhoea. There is often marked mental depression, with an irritability 
of disposition that may be quite foreign to the patient's true character. 
It is most interesting to observe how quickly the symptoms are ameliorated 
when the pus is evacuated and the tension relieved. Within a few hours 
the patient's aspect will have undergone an entire change, and her irritar 
bility and despondency will have disappeared. If the exudation extend 
to the connective tissue in the neighbourhood of the psoas and iliacus 
muscles, and still more, if it involve the connective tissue elements in 
the substance of these muscles, the patient (in order to relax the muscles) 
lies with the thigh of the affected side bent upon the trunk and the leg 
drawn up. 

The general symptoms are those of a subacute form of septicsemia ; 
the local symptoms are often so few and indefinite that the existence of 
an acute inflammatory process within the pelvis may remain for some 
time unsuspected. 

Physical Signs. — In the early days of an attack of acute pelvic 
cellulitis, physical examination gives us but little information. The 
vagina is hot and tender, and its vessels may be felt pulsating ; and that 
is all. After the lapse of several days the physical signs are those of 
inflammatory exudation, at first brawny in consistence and afterwards 
densely hard, in the tissue of the affected area. When the poison has 
entered through a wound in the cervix, the cervix is found to have lost 
its normal mobility, and the supravaginal tissues on the affected side are 
found uniformly tender and more or less hard and unyielding. Owing to 
their swollen condition they cause a depression of the lateral fornix of the 
vagina on that side, sometimes completely obliterating it. It is seldom 
that both sides of the pelvis are equally affected ; but it is by no means 
unusual to find the whole supravaginal portion of the cervix embedded 
in a thick tender collar of indurated tissue, which more or less completely 
surrounds it. In the majority of cases the inflammation spreads laterally 
along the base of the broad ligament of the infected side, and then passes 
forward to the tissue beneath the reflection of peritoneum on the anterior 
abdominal wall. It is at this stage that an area of uniform hardness and 
resistance can be felt in the abdominal wall beneath the muscles. This 
hardness usually takes the form of a broad band, measuring one and a 



PELVIC INFLAMMATION 491 

half to two inches or more in width, and lying along the upper border of 
the inner portion of Poupart's ligament. ^lore rarely the area of hardness 
is confined to the supra-pubic region, whence it may gradually extend 
upwards even as far as the umbilicus. Sometimes the exudation spreads 
upwards and outwards from above Poupart's ligament into the iliac fossa, 
interfering with the action of the psoas and iliacus, and leading the patient 
to keep the thigh flexed in order to relax these muscles. In some instances 
the inflammation passes backwards instead of forwards, producing an 
exudation in the tissue of one or both utero-sacral ligaments, in the tissue 
surrounding the rectum and in that beneath the peritoneum lining the 
posterior pelvic wall. In these cases much information can be obtained 
from a rectal examination, when the rectum will be felt wholly or partially 
surrounded with a hard belt of exudation. As pelvic cellulitis is at least 
as common on the left side of the pelvis as on the right, such an impli- 
cation of the tissue surrounding the rectum is by no means unusual. 
Meantime there is no swelling in the situation of Douglas' pouch, unless 
the case be complicated with pelvic peritonitis. When the body of the 
uterus is the starting-point of the cellulitis, and the broad ligament itself 
the seat of the exudation, bimanual examination will reveal ahard, smooth, 
flattened, slightly movable tumour, by the side of the uterus and insepa- 
rable from it, occasionally displacing it a little towards the sound side.^ 

AYhen there is no suppuration the exudation becomes absorbed, and, 
in uncomplicated cases, the hardness gradually disappears, leaving no 
trace behind. 

Pelvic Abscess. — In a considerable number of cases of pelvic cellulitis 
the inflammation is attended with the formation of abscess. The situation 
of the abscess and the position where it may be expected to point depend, 
of course, upon the direction in which the inflammatory exudation has 
extended. Taking the most common case first, — that, namely, where the 
inflammation is seated in the tissue at the base of the broad ligament, and 
passes forward beneath the peritoneum as it is reflected on the anterior 
abdominal wall, forminganarea of induration above Poupart's ligament, — 
the presence of suppuration is manifested by the occurrence of oedema in 
the skin over the indurated area, which pits on pressure ; by the signs of 
deep-seated fluctuation, and by the eventual pointing of the abscess at a 
site usually a little above Poupart's ligament. This site can often be 
detected long before the pus has reached the surface, by passing the tip 
of the finger carefully over the indurated area, where it can be recognised 
as a soft depression in the midst of the surrounding hardness. Of twenty- 
two cases of cellulitic abscess treated at St. Thomas' Hospital during the 
years 1889-93, the abscess pointed above Poupart's ligament in no fewer 
than eighteen. Whenever pelvic cellulitis extends in such a direction as 
to cause aninduration in the abdominal wall — whether that induration be 
in front of the bladder (supra-pubic), or above Poupart's ligament, or over 
the iliac fossa — it may reasonably be expectedthat,if anabscessbe formed, 

1 An exaggerated importance has been attached to lateral displacement of the uterus as 
a distinctive sign of pelvic cellulitis ; it occurs but rarely, and is of little diagnostic value. 



492 SYSTEM OF GYNECOLOGY 

it will point on the external surface of the body at the site of the indura- 
tion. Unfortunately, pelvic cellulitis, as has already been stated, some- 
times extends in a backward instead of in a forward direction, following 
probably the course of the lymphatics; if, under such circumstances, sup- 
puration occur, the result is less satisfactory : an abscess is then formed 
beneath the peritoneum covering the back of the pelvis, and, as the con- 
tents of such an abscess have no direct access to a free surface, relief is 
much longer delayed and extensive burrowing is almost inevitable. 
Extension into the iliac fossa and the loin is more particularly apt to take 
place when the posterior pelvic wall is thus the seat of an abscess, the 
abscess pointing either at the iliac crest or above it. Sometimes the pus 
leaves the pelvis by the sciatic notch, and follows the course of the sciatic 
and gluteal vessels ; in other instances it makes its appearance in Scarpa's 
triangle, having found its way by the side of the femoral vessels. By 
whatever route the pus makes its way out of the pelvis it "does so by 
following the track, not of nerves or of tendons, but of the blood-vessels 
and other parts, such as the ureter, which are accompanied by a prolon- 
gation of the connective tissue as they enter or leave the pelvis. It is 
sometimes stated that a pelvic abscess may follow the course of the psoas 
muscle ; but when matter burrows along the psoas it comes not from a 
cellulitic abscess, but from dead bone. 

The statement, so commonly made, that cellulitic abscesses frequently 
burst into the rectum, the vagina, and the bladder, appears to rest on 
very slender foundation. Many of the cases quoted in its support belong 
to a time when little was known of the pathology of pelvic inflammation, 
and on reading them in the light of our present knowledge it is easy to 
see that at least a considerable number of the cases reported as cellulitic 
abscesses were really cases of intraperitoneal suppuration, originating in 
suppurative disease either of the Fallopian tubes or the ovaries. There 
is, however, no anatomical reason why cellulitic abscesses should not 
occasionally discharge themselves into the rectum, vagina, or even the 
bladder ; and some of the cases on record appear to be genuine examples 
of such an occurrence. 

The usual time for an abscess to point is from the seventh to the 
twelfth week. The earliest period at which I have known pointing to 
occur is five weeks, the latest fourteen. 

Diffuse Pelvic Supjmration. — In connection with this subject of abscess 
in the pelvic connective tissue I must mention a peculiarly malignant form 
of pelvic inflammation, occurring for the most part in puerperal women, 
in which, in addition to other lesions significant of the virulence of the 
septic infection, there are found after death multiple abscesses in the 
connective tissue, many of them so small as easily to escape detection 
unless carefully looked for. This affection has all the characters of 
phlegmonous erysipelas. The tissues involved are oedematous and of 
a livid hue ; suppurating thrombi are found in the veins, and the 
lymphatics are seen to be acutely inflamed. In a considerable proportion 
of the cases the ovaries are found to be in a state of suppuration, and 



PELVIC INFLAMMATION 493 

there is usually evidence of extension of the inflammation to the pel- 
vic peritoneum. Such cases are attended with all the symptoms of 
septicaemia in its most intense form and are rapidly fatal. 

Diagnosis. — As pelvic cellulitis is usually unattended with pain, it 
has often made considerable progress before its presence is suspected. 
Puerperal women very naturally show a repugnance to vaginal examina- 
tions, owing to the tenderness of the external genitals and the presence 
of the lochia. When the puerperium runs a normal course this feeling 
is very properly respected, and the medical attendant is justified in 
abstaining from the infliction of the unnecessary pain and annoyance 
occasioned by digital examination. But it cannot be too strongly 
pointed out that the justification for this abstention ceases when 
symptoms of pyrexia supervene, and when it becomes evident that the 
ordinary course of recovery is interrupted. A temporary elevation of 
temperature ma}', of course, occur from such causes as constij^ation and 
the influence of the emotions. As soon, however, as the medical 
attendant has satisfied himself that the symptoms are not of this 
transient nature, it becomes his duty, especially if the lochia be offensive, 
to make a thorough examination not only of the vagina, but of the in- 
terior of the uterus which, during the first ten days after delivery, can 
easily be explored by the bimanual method without resorting to 
artificial dilatation. If the result of this examination be the discover}- 
of a fragment of placental tissue or a decomposing blood-clot within the 
uterus he will of course remove it, and adopt suitable measures for 
cleansing and disinfecting the uterine cavity, with the almost certain 
prospect of thereby promptly relieving the symptoms. If not, he will 
have eliminated the most probable cause for the pyrexia, and will, at the 
same time, have had an opportunity of detecting any swelling or other 
morbid condition in the tissues surrounding the uterus and vagina. 
Within a very few days of the onset of the attack the physical signs of 
pelvic cellulitis become sufiiciently well marked to leave no room for 
doubt as to the diagnosis; and the discovery of a laceration of the 
cervix or of the vaginal wall will usually indicate the probable channel 
through which the infection gained an entrance. Frequently one of 
the earliest signs of cellulitis is an impaired mobility of the cervix, with 
tenderness and swelling on one side of it. A little later the inflamed 
tissue becomes stiff, and the stiffness quickly increases into a well-defined 
hardness. The inflammation may gradually extend all round the upper 
part of the cervix ; or may spread outwards along the base of the broad 
ligament of the affected side, depressing the lateral fornix of the vagina 
and sometimes obliterating it. At a later stage the induration will, in 
the majority of cases, extend to the sub-peritoneal connective tissue 
above Poupart's ligament, and become evident on external examination 
as a brawny, tender swelling in that region. The diagnosis of the pres- 
ence of pus has already been described. When the direction taken 
by the cellulitis is towards the posterior part of the pelvis, an examina- 
tion per vaginam of the posterior pelvic wall on both sides will usually 



494 SYSTEM OF GYNECOLOGY 

reveal a diffused fulness and hardness on the affected side as compared 
with the sound side; whilst a rectal examination will, owing to the 
infiltration of the tissues surrounding the middle portion of the rectum, 
render the diagnosis still more certain. 

In the rarer case of the broad ligament proper being the part 
affected, the diagnosis is made by finding the mobility of the body of 
the uterus impaired by the presence of a more or less flattened mass of 
induration on one side of the body and continuous with it. This mass 
is capable of a certain amount of movement backwards and forwards 
Avhen held between the two examining hands. It does not extend into 
the posterior pelvic fossa. 

Except along the plane of tissue between the cervix uteri and the 
bladder, the cellular area of one side of the pelvis is more or less shut 
off from direct communication with that of the other side by the close 
attachment, in the middle line, of the visceral peritoneum to the bladder, 
fundus uteri, and rectum. Hence pelvic cellulitis is for the most part 
unilateral. 

The differential diagnosis between pelvic cellulitis and pelvic peri- 
tonitis will be more conveniently considered when the physical signs 
of the latter affection have been described. The only other conditions 
likely to be confounded with pelvic cellulitis are haematoma of the broad 
ligament and myoma of the uterus. In hsematoma of the broad liga- 
ment there is an effusion of blood into the connective tissue of the 
ligament, which forms a slightly movable, somewhat flattened tumour 
by the side of the uterus and continuous with it, simulating that rare 
variety of pelvic cellulitis which affects the broad ligament proper. 
The history of the case and the absence of symptoms of severe illness 
will, as a rule, serve sufficiently to distinguish a hsematoma from an in- 
flammatory condition. Hsematoma occurs suddenly, either from the 
rupture of a pregnant tube into the connective tissue between the layers 
of the mesosalpinx, or from rupture of a varicose vein in the broad 
ligament. In either case the onset is usually marked by sudden pain 
and faintness and usually also by an attack of vomiting. In the case 
of rupture of a pregnant tube one or more menstrual periods will 
probably have been missed, and attacks of pain will have occurred in 
the lower part of the abdomen, generally on one side, with slight 
irregular haemorrhages from the uterus. The effect of a sudden out- 
pouring of blood into the tissues of the broad ligament, so far as the 
temperature and pulse are concerned, is transient. Hence when the 
haematoma has existed for a few days the temperature and pulse 
become normal. The possibility, however, of the haematoma becoming 
infected and undergoing suppuration must be borne in mind. Should 
this occur, the symptoms will be similar to those of pelvic abscess due 
to cellulitis. 

In regard to myoma of the uterus, it certainly seems extremely 
unlikely that this disease could ever be mistaken for a cellulitic 
exudation. Now and then, however, a case occurs in which a myoma 



PELVIC INFLAMMATION 495 

develops itself laterally between the layers of tlie broad ligament, fixing 
the uterus and forming a more or less hard tumour directly continuous 
with it. Should a localised peritonitis take place around such a tumour, 
or should such a tumour become inflamed or gangrenous, the diagnosis 
might be attended with considerable difficulty. A myoma in the 
posterior wall of the uterus could scarcely give rise to misleading signs ; 
large inflammatory exudations into the connective tissue behind the 
cervix uteri being extremely rare. Similarly, a myoma in the anterior 
wall of the uterus is not likely to be mistaken for cellulitis, the signs of 
cellulitic exudation between the bladder and the upper part of the cervix 
being well marked and highly characteristic. 

Prognosis. — Except in the diffuse variety of pelvic cellulitis, in 
which the cellulitis is only a part of a general septic process of the most 
acute and fatal type, the disease usually terminates in recovery. As 
soon as the fever subsides the exudation begins to undergo absorption, 
and under favourable circumstances it will have entirely disappeared in 
a few weeks. Unlike pelvic peritonitis, cellulitis, when uncomplicated 
by peritonitis, leaves no unpleasant results such as adhesions or dis- 
placements. The recovery is complete. An attack of pelvic cellulitis 
is therefore no bar to subsequent pregnancy. 

If the fever do not subside in the course of five or six weeks sup- 
puration has probably occurred. The duration and progress of the 
illness will then largely depend on the direction that the pus may take 
in its efforts to reach the surface. In the large majority of cases the 
abscess will point above Poupart's ligament, where it can be opened 
easily and satisfactorily before much burrowing has occurred. These 
cases almost invariably do well. In the rarer cases, where suppuration 
occurs at the back of the pelvis, the pus is longer in reaching a surface 
and is apt to burrow in different directions. Such cases often last a 
long time and are very trying. They are more apt, too, to be com- 
plicated by extensions to the peritoneum. 

It is often stated that troublesome sinuses are a not infrequent 
result of pelvic abscess. I have never myself yet seen a troublesome 
sinus result from opening a cellulitic abscess in the pelvis on the surface 
of the body ; and I strongly suspect that the cases in which such sinuses 
have occurred have not been cellulitic abscesses, but suppurating ovarian 
cysts, or other non-celiuiitic forms of pelvic suppuration. Similarly, 
cellulitic abscesses are said to burst into the rectum, vagina, and bladder, 
and to form fistulas in consequence. I believe this assertion to be, 
generally speaking, ill-founded. It must be a very rare occurrence for 
cellulitic abscesses to open into these organs ; the abscesses that com- 
monly open into them are the result of suppuration in the tubes or 
ovaries. It is easy to understand that such abscesses will not un- 
frequently be followed by fistula. But under ordinary circumstances 
a true pelvic abscess, that is, a cellulitic abscess, discharges its con- 
tents and disappears. 



496 SYSTEM OF GYNECOLOGY 

Treatment. — If the views here set forth concerning the uniformly 
septic origin of pelvic cellulitis be correct, the preventive treatment of 
the disease may be summed up in a very few words : it will consist in a 
strict regard to asepsis, or surgical cleanliness, in all midwifery cases 
and in all surgical manipulations of the female genital organs. If free- 
dom from infection could be ensured to the parturient woman pelvic 
cellulitis would, for all practical purposes, disappear ; and if a similar 
freedom could be extended to every woman who is submitted to vaginal 
examination and manipulation the disappearance of the disease, as a 
primary affection, would be complete. 

It is very doubtful whether, when once an attack of pelvic 
cellulitis has been lighted up, it is possible to modify the course 
of the disease by any medication, internal or external. In this un- 
certainty it behoves us at least to be careful not to do our patients 
any harm. The remedies against the abuse of which I consider it 
specially desirable to utter a word of warning are opium and the anti- 
pyretics. Opium in one form or another is frequently given as a 
matter of routine. The result is a further disturbance of the already 
disturbed digestive functions, and an aggravation of one of the principal 
difficulties with which the physician has to contend, namely, constipa- 
tion. Opium and morphia should be reserved for cases complicated with 
peritonitis, and therefore attended with pain ; and should be given with 
the sole object of relieving pain. Similarly, antipyretics (including 
quinine when administered in large doses) should be reserved for the 
rare occasions when the temperature is so high as to constitute in itself 
a source of danger. When there is no special therapeutic indication, a 
simple saline mixture containing liquor ammoniae acetatis or potassium 
citrate, or some acidulated vegetable tonic, will be the safest and most 
suitable medicine. The state of the bowels should receive the most 
careful attention. A regular course of aperient medicine at bedtime 
will almost always be required, and will often need the supplement of a 
soap-and-water enema in the morning. The patient's comfort will much 
depend on the care with which fsecal accumulations are avoided. The 
question of feeding is of equal importance. In the acuter stages a 
farinaceous diet is proper, but as soon as possible fish or fowl should 
be given, and a persistence of febrile temperature need be no bar to a 
meat diet if the patient can take it. The tendency to emaciation calls 
for generous feeding, and concentrated foods are only to be used when 
ordinary food cannot be taken. 

Local applications to the lower parts of the abdomen are only 
necessary when induration is to be felt in that situation, or when pain 
is present. Hot flannel fomentations afford most relief ; it is well to 
alternate them with the application of a thick layer of dry cotton wool, 
kept in place, if necessary, by a flannel bandage. The application of 
glycerine and belladonna, at present much in vogue, is of very doubtful 
value. It is inferior to hot fomentations and poultices as a means of 
relieving pain. 



PELVIC INFLAMMATION 497 

The hot vaginal douche, administered at a temperature of 110° to 
115° F., was highly extolled by Dr. Emmet of New York, who believed 
it to be exceedingly efficacious in promoting absorption of the inflam- 
matory exudation. Chiefly owing to his persistent advocacy, it has 
become more popular than any other form of local application ; though 
its remedial effect is very doubtful, it is often a source of comfort to 
the patient, and if administered gently can at any rate do no harm. 
Vaginal tampons of glycerine have for man}^ years been in favour as 
an additional means of hastening the disappearance of inflammatory 
thickening. More recently, tampons soaked in a 15 per cent or 20 per 
cent solution of ichthyol in glycerine have been recommended for the 
same purpose. The remedial value of these applications is probably 
very slight. 

When matter forms the case is to be dealt with on recognised sur- 
gical principles ; the abscess should be opened as soon as fluctuation is 
detected, or there is the faintest indication of pointing. In ordinary 
cases the drainage tube is required for a very few days only. In the 
great majority of cases the incision will be made externally. In this 
form of pelvic suppuration abdominal section is, in my experience, 
entirely uncalled for. Should the abscess point in the vagina, it must 
of course be opened there. Most, however, of the fluctuating swellings 
felt through the vaginal roof are not cellulitic abscesses, but come into 
quite a different category. 

Before concluding the subject of treatment, I desire to call attention 
to the need, in those cases in which the patient lies day after day with 
the knee and thigh flexed, of guarding against permanent contraction of 
the knee-joint. This distressing result may generally be avoided by 
instructing the nurse to place her hand beneath the heel, to raise it 
sufficiently high to straighten the knee, and to hold it in this position 
for a few minutes twice a day. 

Chroxic Pelvic Cellulitis 

Chronic pelvic cellulitis does not exist as an independent affection, or 
as a sequel to the acute disease above described ; but it occurs occasionally 
as a secondary result of purulent salpingitis or other intrapelvic suppura- 
tive inflammation. It only involves the parts immediately contiguous to 
the inflamed structures, and never gives rise to the broad band of indura- 
tion in the lower part of the anterior wall of the abdomen so common 
in the primary affection. 

The induration to which it does give rise introduces, of course, for 
the time being, an element of obscurity into the diagnosis of deep-seated 
inflammatory lesions in the pelvis ; but it generally subsides under the 
influence of rest, thus at the same time establishing its true nature, and 
removing the difficulty interposed in the way of a satisfactory bimanual 
examination. 

This variety of pelvic cellulitis is seldom or never attended with 

2k 



498 SYSTEM OF GYNECOLOGY 

cellulitic abscess ; it is cliaracterised chiefly by oedema and small-celled 
infiltration of the connective tissue concerned. 



Pelvic Peritonitis 
(Synonyms. — Perimetritis, Perisalpingitis, Perioophoritis) 

Definition and Nature. — Pelvic peritonitis is an inflammation of that 
portion of the peritoneum which is situated within the pelvis. It is a 
much more common affection than pelvic cellulitis, and is perhaps met 
with more frequently than any other inflammatory disease in the pelvis. 
In the vast majority of cases (if not indeed in all) it is an infective 
process, due either to the presence of micro-organisms or to their chemi- 
cal products. Its action may, nevertheless, be regarded as in the main 
beneficial. Not only is it, in itself, an effort on the part of the organism 
to resist and do battle with the invading foe, but, by erecting barriers 
around the diseased area, it tends to narrow and confine the field of in- 
fection and thus to shield the neighbouring structures from damage. 

In his Lettsomian Lectures for 1894, delivered before the Medical 
Society of London, Mr. Frederick Treves emphasises very forcibly this 
view of the nature of peritonitis. '' The purpose of peritonitis," he 
says, " is towards the saving of life, and not towards the destruction 
of it." This purpose is not always fulfilled. The poison may be too 
virulent, or may be present in too great quantity for the inflammatory 
process to cope with it successfully ; or again the inflammatory process 
itself may be excessive, and, like most agencies that are powerful for 
good, may occasionally be powerful also for harm. 

Etiology. — Pelvic peritonitis probably never occurs otherwise than 
as a result or complication of some pre-existing disease within the pelvis. 
Not unfrequently, however, it is the first indication of the presence of 
such disease ; for the symptoms of peritonitis are for the most part acute 
and of a character to compel attention, whereas those of the original 
disease are often so slight as to be scarcely noticeable. Hence it happens 
that in many cases, until an operation or an autopsy discloses the disease 
which was its starting-point, all we can say with certainty is that pelvic 
peritonitis is present. Under such circumstances it is not surprising 
that pelvic peritonitis was for a long time, and by some persons is still 
regarded as being, occasionally at least, a primary idiopathic inflamma- 
tion, the result of such simple causes as injury, exposure to cold, or the 
sudden arrest of menstruation. 

As our knowledge advances it is becoming more and more doubtful 
whether this is ever the case. It is true that instances occur in which 
no pre-existing disease is discovered ; but the number of such cases is 
diminishing so rapidly that the failure to discover it in a particular case 
is much more likely to be due to imperfections in our knowledge and in 
our powers of observation than to its non-existence. 



PELVIC INFLAMMATION 499 

Salpingitis and its Complications. — In tlie vast majority of cases, 
pelvic peritonitis in ^voman is the result of inflammation of the Fallo- 
pian tube. Other causes will be pointed out presently 5 this, being much 
the most common one, claims our first and chief attention. 

The mucous membrane lining the Fallopian tube is, at the abdominal 
ostium of the tube, continuous with the peritoneum ; whilst at the inner 
or uterine end of the tube it is continuous with the mucous membrane 
lining the nterine cavity. Thus there is direct communication between 
the uterus and vagina on the one hand and the peritoneum on the other. 
Owing to the continuity of its lining membrane with that of the uterus 
and vagina, the Fallopian tube is exposed to constant risk of infection, 
and the tendency of acute infective endometritis, whether septic, 
gonorrhoeal, or tubercular is to spread to and involve the tube. From 
the mere fact of the direct continuity of the structures concerned the 
extension of the infection to the peritoneum is rendered almost inevita- 
ble; but the risk is still further increased by the peculiar anatomical 
position of the Fallopian tube in the human subject. ^N'o other mucous 
canal in the body is similarly situated. When, for example, the mucous 
membrane lining the uterus is inflamed, the patency of the cervical canal 
provides a natural outlet for the morbid secretions. In the Fallopian 
tube there is no such natural outlet. The uterine end of the tube, 
under normal circumstances, has a lumen oaly just large enough to 
admit a fine bristle. It will, therefore, be readily understood that a 
very slight amount of swelling of the mucous membrane, such as is 
probably inseparable from the mildest inflammatory attack, may block 
this end completely. Hence, as an outlet for inflammatory secre- 
tions, the uterine orifice may be regarded as practically non-existent. 
If there is, therefore, any outlet for them at all it is into the peritoneal 
cavity. It is this absence of a suitable outlet for the morbid secretions 
of the tube, and the continuity of the lining membrane of the tube with 
the peritoneum, that together give to the inflammatory affections of the 
tube such an exceptional importance, and make pelvic peritonitis so 
constant a sequel of salpingitis. 

There are other ways, besides direct extension and the escape of 
inflammatory products, in which pelvic peritonitis may result from in- 
flammation of the Fallopian tube. It is by no means an uncommon result 
of the inflammatory process for the abdominal ostium of the tube to be- 
come sealed by adhesions, or by inflammatory changes in the fiuibrise. 
The morbid secretions are then retained within the tube, which thus 
becomes a centre around which the inflammatory process spreads through 
the wall of the tube to the neighbouring tissues, and chiefly to the peri- 
toneum. Even if this extension do not immediately occur, the diseased 
tube is constantly liable to fresh inflammatory attacks from slight causes, 
and these may at any time extend to the peritoneum. If the pent-up 
secretion consist of pus, as is frequently the case, not only is the liability 
to recurrent attacks of pelvic peritonitis more marked than when the 
accumulation is merely serous or niuco-purulent, but there is the added 



500 



SYSTEM OF GYNECOLOGY 



danger of ulceration of the tube wall with the possibility of the pus 
escaping into the peritoneum by perforation. 

Sometimes the inflamed Fallopian tube infects the ovary, causing it 
to suppurate, and a fresh source of danger to the peritoneum is thus pro- 
duced. The Fallopian tube must still be regarded as the starting-point ; 
but instead of affecting the peritoneum directly, it does so in this instance 
indirectly, through the medium of the inflamed ovary. Under such 
circumstances the inflamed tube and ovary may both act as the sources 
of pelvic peritonitis; but, occasionally, the tube, after infecting the 
ovary, so far recovers as to be itself no longer a centre of fresh mischief, 
and an attack of peritonitis may then be due directly to the ovarian 
condition. Secondary infection of the ovary appears to be particularly 
apt to occur when the ovary is already the seat of cystic disease ; and 
simple abscess of the ovary is much less common than suppuration in 
an ovarian cjst. The most usual mode of infection is through the cyst 
wall, at a spot where it has become adherent to the diseased tube. Occa- 
sionally, however, infection takes place by an ulcerative process, which 
allows the contents of the suppurating tube to escape suddenly by per- 
foration into the interior of the cyst. This is the ordinary way in which 
a tubo-ovarian abscess is formed. Such a sudden extension of the suppura- 
tive process invariably provokes a fresh outburst of peritonitis, the 
attack being usually much more severe and dangerous than any that has 
preceded it. A still more alarming peritonitis is set up when the con- 
tents of a suppurating tube or of a suppurating ovary escape by ulcera- 
tion into the peritoneal cavity. Fortunately it very seldom happens 
that such an escape takes place primarily into the general peritoneal 
cavity, so as to cause a diffuse suppurative peritonitis : the escape usu- 
ally occurs into a space limited by adhesions, and results in an intra- 
peritoneal abscess. An abscess so formed rapidly enlarges, and, if 
allowed to go on and the patient survive, eventually bursts, according to 
its situation, either into some neighbouring canal or viscus, or into the 
general peritoneal cavity, or on the surface of the body. 

Although suppuration of an ovarian cyst is usually the result of 
infection from an inflamed Fallopian tube, it may occur independently 
of tubal disease. There is reason to believe, for example, that the 
infection is occasionally due to the contiguity of the rectum or some 
other portion of the intestine. This is especially likely to happen when 
the tissues have been injured by bruising, as in the process of parturi- 
tion. Peritonitis may also result from twisting of the pedicle of an 
ovarian tumour. Experience sh o ws that this accident — with consequent 
strangulation, intra-cystic haemorrhage and inflammation or necrosis, ac- 
cording to the degree of strangulation — is particularly apt to take place 
during parturition. Hence, whenever puerperal peritonitis arises, the 
possibility of its source in this accident should be borne in mind. That 
an ovarian tumour was not previously known to exist by no means 
excludes it from consideration. 

JSfew Groivths, etc. — Apart from these complications, any new growth 



PELVIC INFLAMMATION 501 

in the pelvis may, by its mere presence, set up peritonitis. The frequency 
of adhesions in ordinary cystic disease of the ovary is sufficient proof of 
this. But tumours vary considerably in their tendency to excite the 
inflammatory process in the surrounding peritoneum. Thus it is excep- 
tional to meet with peritonitis as a result of the presence of uterine 
myomas, even if very large, unless the tumours have undergone de- 
generative changes ; whilst papilloma of the ovary and tube, dermoids 
of the ovary and malignant disease, are seldom found without evidence 
of more or less extensive peritonitis. 

Severe Septicaemia. — When septic infection of a severe type follows 
abortion, parturition, or surgical manipulations of the female genital 
organs, instead of limiting itself to an attack upon the mucous lining of 
the genital canal, it may spread along the lymphatics and the veins, and 
so give rise to a diffuse septic infection of the pelvis, involving, amongst 
other tissues, the peritoneum. In some cases a peritonitis so produced 
remains localised in the pelvis ; but much more frequently the inflamma- 
tion becomes general, and an acute general septic peritonitis is the result. 
Associated with this condition is usually found a diffuse pelvic suppura- 
tion of a peculiarly malignant form, a condition already described in the 
chapter on pelvic cellulitis. 

Injury. — Both the teachings of bacteriology and clinical experience 
tend to show that injury alone will not cause peritonitis ; and that it is 
only when the hand or instrument with which the injury is inflicted is 
surgically unclean that the inflammatory process is excited. In illustra- 
tion of this, we may contrast the rarity with which evil effects folloAV the 
most extensive injuries to the peritoneum inflicted during a difficult and 
severe case of abdominal section — say for the removal of a tumour in the 
broad ligament — or the accidental perforation of the unimpregnated ute- 
rus by the curette or uterine sound, with the terrible results that so fre- 
quently follow bungling attempts to produce criminal abortion. In fatal 
cases of the latter kind it is generally found that death has resulted from 
acute septic peritonitis, with a punctured wound of the uterus or adjacent 
tissues for its starting-point. It cannot be doubted that the question is 
entirely one of infection. The operator in such cases is almost invariably 
found to have been either very ignorant or very reckless, — in either case 
an extremely unlikely person to have adopted precautions against in- 
fection. 

Allusion has already been made to another way in which injury may 
determine an attack of pelvic peritonitis. The shape and size of the 
normal female pelvis are such as to fit it for the passage of a normally 
sized child at the full term, but are not such as to enable it to accommo- 
date anything beyond that. If therefore the pelvic space is encroached 
upon by a new growth, the size of which cannot be reduced or its posi- 
tion altered — as, for example, by a small adherent multilocular ovarian 
tumour — an obstacle is offered which either prevents parturition by the 
natural passages altogether, or renders it possible only at the expense of 
much bruising of the tumour. Should the latter event occur, the vitality, 



502 SYSTEM OF GYNAECOLOGY 

and, with, it, the resisting power of the tumour are lowered, so that it falls 
an easy prey to pathogenetic micro-organisms, whether they attack it 
from the uterus in front or the rectum in the rear. In this way the oc- 
casional occurrence of puerperal peritonitis from suppurative inflamma- 
tion of an incarcerated and contused ovarian cyst is to be explained. 

Pelvic Cellulitis. — As pelvic cellulitis may be, and very frequently 
is, secondary to other forms of pelvic inflammation, so pelvic peritonitis 
may be the result of the spread of the inflammatory process from the 
adjacent connective tissue. This is especially apt to take place whjen the 
cellulitis is attended with suppuration, or when the portion of connec- 
tive tissue chiefly involved is that which lies in the posterior part of 
the pelvis. 

Pelvic Hmmatocele. — The slighter haemorrhages that occur within the 
pelvic peritoneum, and especially those which take place from the open 
fimbriated end of the Eallopian tube in the early stages of tubal preg- 
nancy, usually result in the formation of a pelvic hsematocele. The 
effused blood becomes shut off from the general peritoneal cavity, partly 
by the firm coagulation of its outer layer, but chiefly by the glueing to- 
gether of the parts around it by adhesive peritonitis. In this way the 
collection of blood becomes roofed in by adherent omentum and coils 
of intestine, the peritonitis thus serving to limit the eft'usion and con- 
ducing to its ultimate absorption. 

Disease of the Apjpeyidix Vermiformis. — Although it is not within 
the scope of this work to deal with diseases other than those which are 
peculiar to women, no account of the etiology of pelvic peritonitis would 
be satisfactory that did not include some reference to one at least of the 
causes that are common to both sexes, namely, disease of the appendix 
vermiformis. The normal position of the appendix is in the iliac fossa, 
above the brim of the pelvis; but instances are by no means uncom- 
mon in which the appendix is found lying within the pelvis, and it 
therefore becomes necessary when investigating a case of pelvic perito- 
nitis, especially if the right side be the part chiefly affected, to bear in 
mind the possibility that the inflammation may be of intestinal origin. 
There is another way in which the diagnosis may be obscured. It has 
been shown, by the study of frozen sections, that towards the latter part 
of pregnancy the uterine appendages and broad ligaments are elevated 
completely out of the true pelvis ; the consequence is that they are 
brought at that time into close contiguity with the caecum and its ap- 
pendix. If the appendix, then, happens to become diseased, or, being 
already diseased, happens to set up an attack of peritonitis during this 
temporary displacement of parts, the pelvic peritoneum, broad ligament, 
and uterine appendages will almost certainly be involved and the diffi- 
culty of diagnosis thereby greatly increased. 

It is obvious that, within the limits of space at our disposal, it would 
be impossible to furnish anything like an exhaustive account of the 
etiology of pelvic peritonitis. The bacteriology, for example, has of 
necessity been entirely omitted. I hope, however, that what has been 



PELVIC INFLAMMATION 503 

said will convey some idea of the relative importance and comparative 
frequency of the principal causes of pelvic peritonitis, and will serve 
to emphasise the fact that pelvic peritonitis is no longer to be regarded 
as a disease in itself, but as an indication of the existence of some other 
disease, the nature of which it is our first duty at the bedside to discover. 

Pathological Anatomy. — The earliest change produced in the perito- 
neum by inflammation is hypersemia, with cloudy swelling of the endothe- 
lium. The membrane loses its normal smooth, shining appearance, and 
becomes dull, dry, and slightly roughened. Plastic lymph is then poured 
out on the surface, and this leads to the rapid formation of adhesions be- 
tween adjacent surfaces. The adhesions thus formed are the most charac- 
teristic feature of pelvic peritonitis. In cases where the inflammation is 
recurrent fresh adhesions take place during each attack, so that there are 
often in the same patient adhesions of different ages and varying density. 
In addition to the effusion of lymph there is also effusion of serum : this 
serum tends to accumulate principally in the pouch of Douglas ; but it 
also forms collections of fluid in different parts of the pelvis, wherever 
spaces intervene amongst the adhesions.^ Thus are formed distinct and 
limited swellings which often simulate a true cyst. One of the earliest 
results of the adhesive process is to roof in the contents of the pelvis at 
the level of the brim, and to shut off the cavity of the pelvis from that of 
the general peritoneum. AVhen the quantity of plastic lymph thrown 
out is at all considerable, the lymph coagulates on the surface of the 
peritoneum, forming a distinct coating which can be peeled off like a 
membrane. Lymph coagula are also formed in the effused serum, and 
may be found either floating in the fluid or deposited on the surrounding 
surfaces. As its fluid portion becomes absorbed, this coating of lymph 
stiffens the peritoneum and, with the induration of the subjacent cellular 
tissue due to secondary cellulitis, contributes to produce the hardness 
which is one of the most striking of the physical signs of pelvic perito- 
nitis in its later stages. The intraperitoneal collections of serum are 
gradually absorbed ; but the adhesions continue for a long time, and many 
of them become permanent, with the result of producing more or less 
serious interference with the functions of the viscera involved. The 
evidences of inflammation are usually most strongly marked around the 
fimbriated end of the Fallopian tube, and diminish in intensity as the 
distance from that point increases. This is exactly what our knowledge 
of the etiology of pelvic peritonitis would lead us to expect. Inasmuch 
as the large majority of cases of pelvic peritonitis originate in salpingitis, 
it is not surprising that the firmest adhesions are met with at the mouth 
of the tube binding the fimbriae to the part with which they happened 
at the time to be in contact. Where the peritonitis has not originated in 
salpingitis, but in some other morbid condition, such as a suppurating 
ovary or a diseased appendix vermiformis, the inflammation is most 

1 Peritonitis attended -with the effusion of serum has been quite unnecessarily described 
as a special variety of pelvic inflammation under the name of serous perimetritis. 



504 SYSTEM OF GYNECOLOGY 

severe, and the adhesions are most dense at the seat of origin, wherever 
that may be. 

It is usual for the Fallopian tube, when inflamed, to sink below its 
ordinary position, so that its abdominal ostium lies either upon the floor 
of the lateral fossa of the pelvis or in the pouch of Douglas. In other 
cases the tube, after embracing the ovary, becomes adherent by its 
fimbriated end either to the ovary itself or to a part of the posterior 
surface of the broad ligament internal to the ovary. In many instances 
the two tubes meet, and their distal ends become adherent to each other 
behind the supravaginal portion of the cervix uteri in the middle line. 
Less frequently the direction taken by the tube is different on the two 
sides: one tube is bent upon itself, with the usual horse-shoe curve, 
and terminates behind the broad ligament or upper part of the cervix 
uteri ; the other tube runs at first sharply forwards, then doubles upon 
itself, forming a loop or knuckle, and finally runs outwards and 
slightly backwards to terminate against the lateral wall of the pelvis, 
and become adherent to it by its abdominal opening. In puerperal 
cases where, as has been already pointed out, the tube is lifted out of 
the pelvis by the development of the pregnant uterus, the mouth of the 
tube, and hence the chief area of the peritoneal inflammation, will be 
found at or near the pelvic brim close to the border of the psoas muscle. 

Wherever the mouth of the tube may be, the ovary is almost invari- 
ably found implicated in the inflammatory process, and adherent over 
its entire surface — partly to the diseased tube, partly to the back of the 
broad ligament. In cases of old standing it is very common to find the 
ovary the seat of incipient cystic disease, and considerably enlarged. 
There is strong reason to believe, though there is as yet no definite 
proof, that this condition of the ovary is occasionally the result of 
changes induced by the surrounding peritonitis. Whenever the tube 
and ovary are bound to each other, the intervening portion of broad 
ligament — called the mesosalpinx — if it have not already been opened 
out and appropriated as part of the covering of the expanded tube, 
usually becomes creased, folded, and so intimately bound up with the 
adhesions as for all practical purposes to be effaced. 

In chronic cases, it is very usual to find the peritoneum in the neigh- 
bourhood of the adherent mass lifted up here and there by circumscribed 
collections of serous fiuid in the meshes of the delicate connective tissue 
immediately subjacent to the peritoneum. These swellings vary in size 
from that of a pea to that of a large orange. They are of no pathological 
importance, but often introduce difficultiesinthe way of accurate diagnosis. 
The mass formed by the agglutination of the tube, ovary, and broad 
ligament, is usually found to have become adherent posteriorly, to the 
peritoneum covering the posterior pelvic wall and the rectum. Some- 
times one or more coils of intestine and a portion of the omentum 
intervene and become implicated in the entangled mass. The body of 
the uterus is sometimes involved in the adhesions and at other times is 
entirely free; its position remains normal unless the tube or ovary, or 



PELVIC INFLAMMATION 505 

botli, besides being adherent, are enlarged — the former by inflamma- 
tory, the latter by cystic changes — when the uterus is displaced to the 
opposite side and more or less rotated on its longitudinal axis. The 
roofing in of the pelvis is generally effected by adhesion of intestine 
and omentum to the horizontal rami of the pubes below, to each other, 
and to the matted contents of the pelvis posteriorly. 

When the disease causing the peritonitis is purulent in character the 
peritonitis itself is also apt to be purulent ; and instead of accumulations 
of serum amongst the adhesions collections of pus are formed — intra- 
peritoneal abscesses. More rarely general suppurative peritonitis results ; 
this only occurs in septic cases of exceptional virulence, or from the 
sudden bursting into the peritoneal cavity of collections of pus in the 
Fallopian tube or in the ovary. Intraperitoneal abscesses may be single 
or multiple, and may begin in several different ways. The most usual 
way is for the purulent contents of a suppurating Fallopian tube to be 
discharged from the abdominal ostium of the tube into Douglas' pouch 
or into a space bounded by adhesions. Sometimes both tubes discharge 
their contents into a common receptacle, and as the mouth of the tube is 
usually directed downwards and backwards, this receptacle is generally 
the pouch of Douglas. Here a tense fluctuating swelling is formed, easily 
felt through the depressed vaginal roof and also through the anterior 
rectal wall, which is bulged backwards so as to cause a more or less 
serious obstruction of that portion of the bowel. The discharge, how- 
ever, may take place when the tube is not lying with its mouth in the 
usual direction, as, for example, when the salpingitis follows delivery, 
and the tube is situated at or above the pelvic brim as a result of the 
drawing np of the parts during the development of the pregnant uterus. 
The resulting abscess will then obviously be formed, not primarily in 
Douglas' pouch (though it may subsequently find its way there) but in a 
higher part of the pelvis, generally in the neighbourhood of the pelvic brim. 

Purulent salpingitis, however, not uncommonly results in the sealing 
up of the abdominal ostium of the tube; the pus is then confined 
within the closed tube, forming a pyosalpinx. Under these circum- 
stances an intraperitoneal abscess may be formed either by infection 
of the peritoneum through the walls of the tube, or by the bursting of 
the pyosalpinx from ulceration commencing within, or by the spread 
of the infective process to the ovary, causing it to suppurate and to 
become in its turn a fresh focus of infection and the seat of a fresh 
collection of pus liable at any moment to ulcerate and burst. 

An intraperitoneal abscess, walled in by adherent viscera, may either 
run an acute coarse or may remain for some time latent, giving few or 
no indications of its presence. Sooner or later, however, if the patient 
survive, one of two things must happen : either the abscess gradually 
dries up and disappears (which there is good reason to believe does 
occasionally occur in the case of small abscesses with non-virulent con- 
tents), or its walls undergo ulceration, and its contents make their 
escape either into the bowel — usually the rectum or the sigmoid flexure 



5o6 SYSTEM OF GYNECOLOGY 

of the colon — or, more rarely, into the vagina, the bladder, or the gen- 
eral cavity of the peritoneum ; or through some part of the abdominal 
wall. The common way of escape for the contents of an intraperitoneal 
abscess is undoubtedly by the bowel, as that for the contents of a cel- 
lulitic abscess is through the abdominal wall. Other routes than these 
may, in both cases, be regarded as exceptional. 

Intraperitoneal abscesses in the pelvis differ from cellulitic abscesses 
in the same part in another very important respect. For whilst the 
latter as a rule quickly disappear when once they have found an outlet, 
the former are apt to discharge their contents imperfectly, so that 
troublesome sinuses are formed which for months and even for years, 
may remain a source of annoyance if not of serious ill-health. 

Amongst the secondary changes that occur as a consequence of 
these inflammatory processes, there are one or two of such importance 
as to call for special mention. When the salpingitis is unilateral, the 
peritonitis frequently extends to the other side of the pelvis, involving 
the healthy uterine appendages of that side in a mass of adhesions. 
Under such circumstances closure of the abdominal ostium of the 
healthy tube is apt to occur, and to be followed by the development of 
a hydrosalpinx in the manner described in detail by Mr. Doran in the 
article on "Diseases of the Fallopian Tube." Hsematosalpinx, as a 
complication of salpingitis, is much more rare. In the great majority 
of cases, effusions of blood within the tube, and hsematoceles of tubal 
origin, are the consequences of tubal gestation ; but now and then they 
occur as incidents in the inflammatory processes above described quite 
independently of gestation. 

Symptoms. — An attack of pelvic peritonitis is characterised by pain 
in the lower part of the abdomen, usually sudden in its onset, and for 
the first few hours severe in character ; by fever, as indicated by rise of 
temperature and increased rapidity of pulse, and very often by vomiting. 
There is usually more or less intestinal distension, sometimes general, 
sometimes localised. After the acute pain has subsided, movement is 
attended with suffering owing to the tenderness of the inflamed parts. 
The symptoms are usually sufficiently severe to oblige the patient to 
remain in bed for a time ; and the length of time that the patient was 
confined to bed is the best rough test at our disposal of the severity of 
a past attack. E-igors are infrequent, except where the pelvic peritoni- 
tis is part of a diffuse septic inflammation, or where the symptoms are 
due to the intraperitoneal bursting of an abscess, as in the case of rupt- 
ure of a pyosalpinx or a suppurating ovary. Constipation is generally 
met with ; and pain preceding defsecation and during micturition occurs 
if the inflamed part be contiguous to the rectum in the one case and 
the bladder in the other. 

In subacute and chronic cases, pain in the back and inability to 
undergo physical exertion are the most common and may be the only 
symptoms. Menstruation usually becomes more profuse than natural, 



PELVIC INFLAMMATION 507 

and is often accompanied with pain. Trifling causes, such as slight 
over-exertion or exposure to cold, readily provoke localised acute attacks 
of inflammation in patients with chronic pelvic peritonitis. 

Such recurrent attacks are especially apt to occur when the chronic 
pelvic peritonitis is kept alive by the presence of pelvic suppuration. 
Indeed, recurrent localised attacks of peritonitis afford a much more 
valuable guide to the diagnosis of pus in the pelvis than does the 
temperature. In twelve out of thirty of my own operation cases in 
which suppuration was present, the temperature before operation was 
absolutely normal ; and in only twelve of the remainder was the 
temperature distinctly and persistently febrile. 

In severe cases, however, attended with suppuration, patients become 
ill and emaciated, and entirely incapacitated for work or for exertion of 
any kind. In the worst cases of all the patient becomes a bedridden 
invalid. Between the two extremes, the one patient who is wholly confined 
to bed and the other who is scarcely conscious of anything wrong except 
during the occasional acute attacks that serve to betray the existence of 
some deep-seated lesion, there are, of course, all possible gradations. The 
amount of suffering endured by a patient with chronic inflammatory 
disease of the uterine appendages must always largely depend, not only 
on the extent and nature of the disease, but also upon the class of life to 
which she belongs, and the demands made upon her activity. 

During an acute attack of pelvic peritonitis, the patient lies on 
her back and is least uncomfortable when the knees are drawn up. 
There is extreme tenderness to the touch over the lower part of the 
abdomen, with rigidity of the abdominal wall over the affected parts. 
This rigidity is due to contraction of the muscles, and is not under the 
control of the patient's will. In exceptional cases a definite swelling 
can be detected on abdominal palpation. This is the case when the 
inflamed appendages happen to be situated above the pelvic brim ; or 
when the attack is due to suppuration in an ovarian cyst of sufficiently 
large size to be reached on abdominal examination ; or when there is 
an encysted exudation of serum or of pus in front of the uterus, or a 
sufficiently extensive exudation posteriorly to push the uterus forwards 
against the abdominal wall. As a rule, however, there is no swelling to be 
discovered, and any noticeable enlargement is merely that produced by 
local distension of the intestine with flatus. On vaginal examination the 
parts will, at this stage, be too sensitive to permit a satisfactory investiga- 
tion of the lateral regions of the pelvis. If there be any depression of the 
vaginal roof, it will be not lateral, but central ; and will be due to an 
encysted effusion of fluid, serous or purulent, in the pouch of Douglas, 
distending the sac, obliterating the posterior vaginal fornix, and displacing 
the uterus forwards. There may be tenderness and a sense of resistance 
on pressing the fingers upwards into one or both lateral f ornices ; but, 
unless there be a cystic ovary or other cause of unusual enlargement on 
the affected side, it will not be possible to map out any definite swelling 
in the posterior fossae of the pelvis until the acute symptoms have 



5o8 SYSTEM OF GYNECOLOGY 

subsided. When this event has occurred, a careful bimanual examination, 
conducted if possible while the patient is under the influence of an 
anaesthetic, will reveal in the posterior fossa of the pelvis on one or both 
sides of the uterus the presence of a fixed, irregular, tender swelling. 
This begins at the uterine cornu as a cylindrical body about equal in 
thickness to a lead pencil, and is capable of being rolled between the 
fingers ; it runs outwards for a short distance, and then becomes some- 
what suddenly thicker, curves upon itself, completely reversing its direc- 
tion, and finally ends behind the cervix uteri in the pouch of Douglas. 
This swelling consists of the thickened Fallopian tube, adherent to the 
ovary, embracing it in the concavity of its curve, and surrounded on 
all sides by thickened and adherent peritoneum. The uterus is seldom 
pushed aside by this mass, and does not, as in the case of cellulitis of the 
broad ligament, appear to form a part of it. The uterus may, however, 
have been retroverted or retroflexed to begin with, when it will have 
become adherent in its abnormal position ; or it may be pushed forwards 
as a whole by an effusion of serum or pus in the pouch of Douglas. 
Lateral displacement only occurs when there is either exceptional en- 
largement of the diseased tube or of the ovary. Under these circum- 
stances, in addition to the pushing over of the uterus towards the 
opposite side, there may be some bulging of the swelling into the vagina, 
causing a depression of the lateral fornix ; a condition which, generally 
speaking, is much more characteristic of pelvic cellulitis than of pelvic 
peritonitis. When the lateral swelling in the latter affection is large 
enough to produce these displacements, the cause will, in the majority of 
cases, be found to be enlargement of the ovary from cystic disease ; a not 
very uncom.mon complication of inflammation of the uterine appendages. 
The shape and consistence of the lateral swelling vary considerably in 
different cases, and even in the different stages of the same case. Sometimes 
the tube is soft and sausage shaped ; this is specially apt to be the case 
when the abdominal ostium is occluded and the tube is uniformly dis- 
tended. Sometimes the distension affects the outer end only, giving the 
mass the shape of a retort. In other cases the tube becomes irregularly 
distended from sacculation, or is thrown into complicated folds, forming 
sharp knuckles or prominences here and there as it bends upon itself, 
and presenting to the examining finger sausage-like convolutions with 
intervening grooves. Tlie consistence of the mass depends partly upon 
the extent to which the walls of the tube have become thickened, and 
partly upon the amount of induration of the surrounding peritoneum. 
This latter is found to be most marked when the examination is made 
soon after an acute attack. As the patient recovers from the immediate 
effects of such an attack, the hardness of the peritoneum gradually 
diminishes, and the outlines of the adherent appendages become more 
easily defined. In cases attended with suppuration or complicated with 
effusions of serum or pus amongst the peritoneal adhesions, the swelling 
is rendered still more irregular in shape and unequal in consistence. 
In some parts it may be possible to obtain clear evidence of fluctuation. 



PEL VIC INFLAMMA TION 



509 



Diagnosis. — The only conditions likely to be mistaken for pelvic 
peritonitis are pelvic cellulitis and. pehdc hsematocele. 

Pelvic Cellulitis. — Some help in the diagnosis from cellulitis may 
be obtained from the etiology of the two affections. Pelvic cellulitis is, 
to begin ^\ith, a much rarer disease than pelvic peritonitis : its origin is 
exclusively septic, never gonorrhoeal or tubercular ; it is essentiall}^ a 
disease of the puerperium, due to absorption of septic matter through 
wounds of the cervix uteri and vagina occasioned during the process of 
parturition. Over-stretching and laceration of the cervix being likely 
to occur only when the child is of full size, it is rare to find pelvic 
cellulitis following abortion and premature labour. In the cases where 
pelvic inflammation is the result of the absorption of septic matter 
during surgical manipulations, it will be found that it only takes the form 
of cellulitis where the manipulations have involved the integrity of the 
cervical tissues. AYhere the manipulations have been intra-uterine and 
unattended with injury to the cervix, the poison is absorbed not by 
the connective tissue, but by the endometrium, the resulting inflamma- 
tion extending along the mucous membrane of the Fallopian tube to the 
peritoneum. 

It is generally held, and with truth, that the presence of acute pain 
points to the pelvic inflammation being peritoneal. Cellulitis, when un- 
complicated, is a disease unattended with pain, or at any rate with severe 
pain. The sudden onset, then, of acute pain in an attack of pelvic in- 
flammation is an indication that the inflammation has reached the peri- 
toneum. After the acute stage has passed, however, the pain of pelvic 
peritonitis is only felt in standing or walking, though the tenderness 
remains, and is apparent on vaginal examination and on coitus. . 

It must, nevertheless, be remembered that pain in the pelvis, as else- 
where, is a most misleading symptom, and is seldom as severe in cases 
of actual disease as it is in many neurotic conditions in which there is 
no obvious lesion, inflammatory or other. 

In both cellulitis and peritonitis there may be and generally is a 
swelling in the lateral regions of the pelvis ; but, whereas in cellulitis the 
swelling is usually unilateral, smooth, uniform, attended with depression 
and fixation of the vaginal roof, and of stony hardness, in peritonitis it 
is more often bilateral than unilateral, and instead of being smooth and 
of uniform consistence, and conveying the impression of being due to an 
exudation in the tissues immediately subjacent to the vaginal wall, it is- 
irregular in outline, unequal in consistence, and is ascertained on bimanual 
examination to be situated in the fossa behind the broad ligament with a 
certain thickness of normal tissue intervening between it and the examin- 
ing finger. Another point of distinction is that in cellulitis the cervix 
uteri is apt to be surrounded by a hard, thick collar in which it is im- 
movably set ; whilst in peritonitis there is no such girdle of indurated 
tissue, and the impairment of the mobility of the cervix is never so com- 
plete. Further, in cellulitis there is no inflammatory effusion or any 
kind of swelling in Douglas' pouch ; whereas in peritonitis there is 



5IO SYSTEM OF GYNECOLOGY 

almost always either a certain amount of distension from inflammatory 
effusion (serous or purulent), or the pouch is felt to be occupied by a 
hardj irregular, fixed swelling, adherent to the supravaginal portion of 
the cervix uteri, and continuous with the fixed irregular mass situated 
in one or both lateral fossae. 

A similar difference exists in the conditions found on rectal examina- 
tion. In cellulitis the rectum will often be felt to be surrounded, wholly 
or partially, by a belt of exudation of stony hardness, fixing the coats of 
the bowel at that part and narrowing the calibre of the canal. In peri- 
tonitis, on the other hand, any effusion within reach from the rectum 
will be in Douglas' pouch ; it will be less hard, it will not affect the 
mobility of the coats of the bowel to the same extent, and, though it may 
press on the bowel in front, it will not encroach upon it laterally. 

When the broad ligament itself is the seat of a cellulitic exudation, 
bimanual examination will reveal a hard, smooth, flattened tumour by 
the side of and continuous with the uterus, and sometimes displacing 
it slightly to the opposite side. This tumour can be moved backwards 
and forwards within certain narrow limits. The swelling caused by the 
inflamed and adherent appenda ges in pelvic peritonitis is, on the contrary, 
of irregular contour, and is not continuous with the uterus, but on a 
plane behind it, and is quite fixed. 

When the cellulitic exudation has reached the sub-peritoneal connec- 
tive tissue of the anterior abdominal wall, it gives rise to a smooth, hard 
swelling in the deeper layers of the wall itself, either immediately above 
Poupart's ligament, or, more rarely, in the suprapubic region. This 
swelling has a well-defined upper boundary and is quite characteristic, 
there -being nothing in the least like it in pelvic peritonitis. 

In non-suppurative cellulitis the exudation becomes entirely absorbed, 
and the hardness disappears without leaving any trace, except where the 
exudation is in the substance of the broad ligament, when there may be 
some contraction with more or less dragging over of the uterus to the 
affected side. In favourable cases of peritonitis the hardness and thick- 
ening become much less marked ; but the viscera once adherent are apt 
to remain so for an indefinite time, and there is generally to be felt a 
soft, irregular mass in the posterior part of the pelvis for the remainder 
of the patient's life, with some amount of uterine fixation and possibly 
of displacement. 

Finally, suppuration in pelvic cellulitis geoerally takes the form of 
an abscess pointing on the surface of the abdominal wall a little above 
Poupart's ligament, and quickly disappearing when once it has found an 
•outlet; whereas in pelvic peritonitis, if suppuration exist, it is either in 
the Fallopian tube (pyosalpinx), or in the ovary, or amongst the peri- 
'toneal adhesions (intraperitoneal abscess) : its favourite outlet is into 
the large bowel or some other internal part, and it is apt to lead to the 
establishment of troublesome sinuses. 

Pelvic Hcematocele. — The diagnosis of an effusion of blood in the 
pouch of Douglas from effusions of serum or pus depends largely upon the 



PELVIC INFLAMMATION 511 

clinical history of the case, and upon the transient character of the febrile 
disturbance in pelvic haematocele. As pelvic hsematocele, in the vast 
majority of cases, is a complication of tubal pregnancy, there will usually 
be a history of one or two menstrual periods having been passed, and of 
a sudden attack of pain, accompanied with nausea or vomiting and an 
alarming feeling of faintness. The patient will have a blanched appear- 
ance, the pallor being greater than the slight uterine haemorrhage usually 
present is suflB.cient to account for. The effusion, at first distinctly fluid, 
soon acquires a doughy consistence from partial clotting ; and, later, be- 
comes diminished in bulk and harder, as the peripheral portion of the 
effused blood forms a dense fibrinous wall. The possibility, however, 
of the haematocele undergoing suppuration must not be lost sight of. The 
signs and symptoms in such an event will be similar to those of an intra- 
peritoneal abscess with septicaemia. 

Prognosis The prognosis in pelvic peritonitis is much less favour- 
able than in pelvic cellulitis. Not only is the mortality higher, but the 
after-effects, in those patients who recover, are apt to be much more 
troublesome, and are not unfrequently of a character sufficiently serious 
to entail a life of chronic invalidism. The disease which caused the 
peritonitis still remains when the acute attack of peritoneal inflammation 
has subsided, and constitutes a centre around which fresh attacks of 
inflammation are continually liable to occur, either from changes in the 
diseased tissues themselves, or from external agencies (such as exposure to 
cold and damp) of a nature insufficient to excite inflammation in healthy 
tissues, but capable of doing so only too readily when the power of re- 
sistance of the tissues is lowered by disease. 

The tendency to recurrent attacks of peritonitis is more marked in 
cases where the underlying disease is accompanied by pus either in the 
form of pyosalpinx, suppurating ovary, or intraperitoneal abscess. 

The damage done to the uterus, ovaries, and Fallopian tubes during 
an attack of pelvic peritonitis, especially that done to the tube by the 
closure, adhesion, or displacement of its abdominal ostium, frequently has 
the effect of producing sterility ; and even if the gradual absorption of 
morbid adhesions permit the occurrence of conception, the continuance 
of gestation to full term may be rendered impossible owing to inter- 
ference with the normal expansion of the pregnant uterus. It is not 
possible, however, in any given case to be certain that pregnancy cannot 
thenceforth occur ; for experience shows that, even after the most violent 
peritonitis, the parts may recover themselves sufficiently to permit not 
only of subsequent conception, but of normal delivery at term. The 
discreet practitioner, therefore, will always hesitate to commit himself 
to the opinion that his patient cannot again bear children. 

Another not infrequent effect of pelvic peritonitis is permanent inter- 
ference with the normal action of the bowels due to the implication of 
intestine in the pelvic adhesions. Occasionally still more serious results 
follow these adhesions in the form of acute intestinal obstruction. 



512 SYSTEM OF GYNECOLOGY 

It must be remembered, nevertheless, that pelvic peritonitis may result 
in complete recovery, and that the prognosis must be determined by the 
special circumstances of each individual case. 

Treatment. — 1. Preventive. — Inasmuch as in the large majority of 
non-puerperal cases, pelvic peritonitis is due to gonorrhoeal salpingitis, the 
prophylactic treatment consists in destroying the gonorrhoeal infection 
before it has extended to parts beyond the reach of local applications. 
Gonorrhoea in the woman is still regarded in this country as a compara- 
tively unimportant affection, though it probably destroys the health of a 
larger number of women than does even the much more dreaded poison 
of syphilis. As a rule, the earlier indications of the disease pass unre- 
garded : they are attended with but little pain, often with none when the 
urethra is not involved, and the significance of the purulent discharge is not 
realised. Hence it frequently happens that medical advice is not sought 
until the infection has had time to inflict serious, and sometimes life-long 
damage on important organs. And even if advice be obtained earlier, 
the disease is not always regarded seriously or vigorous treatment 
adopted. It does not come within the scope of this article to describe 
the symptoms and treatment of acute gonorrhoea in the female. It must 
suffice to point out that a latent gonorrhoea in the male, supposed to 
have been cured, may be roused by marriage into renewed activity ; and 
that a purulent vaginal discharge, especially if in a recently married 
woman, should always be looked upon with grave suspicion, and its 
treatment undertaken with a due sense of responsibility. 

The preventive treatment of pelvic peritonitis due to septic salpingitis 
— which includes (1) nearly all the non-puerperal cases that are not 
accounted for by gonorrhoea, and (2) all the cases that are traceable to 
abortion, parturition, and surgical manipulation — consists in a rigid 
adherence to the rules of aseptic surgery and midwifery, especially as re- 
gards the thorough and even elaborate disinfection of hands, instruments, 
and sponges. By this means only can we hope, in the midst of our varied 
work, to avoid becoming the occasional carriers of septic infection. 

In those who have once been the subject of pelvic peritonitis, it be- 
comes important to avoid such causes as are likely to provoke a relapse. 
The utmost care, for example, should be exercised to avoid exposure to 
cold and damp, especially during the menstrual period ; and over-exertion 
should at all times be guarded against. Prolonged standing appears to 
be attended with consequences quite as disastrous as excessive exercise, 
and should therefore be avoided with equal determination. It is not 
often necessary for patients in whom, notwithstanding the existence of 
chronic inflammatory disease of the uterine appendages, there is no active 
peritonitis present, to be condemned to lie in bed and lead an invalid's 
life ; but it is nevertheless essential to insist upon their observance during 
each day of definite periods of rest in the recumbent posture. It will 
greatly conduce to the formation of regular habits of this kind for the 
medical attendant to draw up a few simple but definite rules for his 



PELVIC INFLAMMATION 513 

patient's guidance, and strongly insist on their being diligently carried 
out. Scarcely less important than the rigorous avoidance of over-fatigue, 
is the need for constant attention to the state of the bowels. Intestinal 
adhesions have the almost invariable effect of producing habitual consti- 
pation with a tendency to faecal accumulation, a condition highly favour- 
able to the development and migration through the coats of the bowel 
of pathogenetic micro-organisms. Hence no effort should be spared, by 
means of suitable aperients, supplemented, if necessary, by enemata of 
glycerine or soap and water, to overcome in these patients any tendency 
to intestinal inaction, and to ensure a thorough emptying of the larger 
bowel every day. 

2. Medical. — The medical treatment of pelvic peritonitis consists in 
very much the same measures as those recommended for the relief of 
pelvic cellulitis, with the important difference, that whereas opium and 
its derivatives are never needed in uncomplicated cellulitis, they may be 
necessary in pelvic peritonitis in order to relieve the acute pain. Even 
then, however, their administration should be regarded as an unavoidable 
evil, and should be discontinued at the earliest possible moment. The 
constipating effects of the opium or morphia should be promptly obviated, 
all prejudices to the contrary notwithstanding, by efficient aperients or 
enemata, or both. The accumulation of scybala is much more powerful 
for harm than the action of purgative medicine, and there should be no 
hesitation as to the choice of the lesser evil. 

Rest in bed is, of course, essential during an acute attack. The diet 
should be restricted, if not to liquid food, at any rate to food of the 
simplest and most digestible character, which should be taken at regular 
intervals so as to allow adequate time for digestion. Pain should be 
relieved by the application of hot flannel fomentations, and distension 
by enemata. Should the patient be tormented with thirst the frequent 
sipping of hot (not lukewarm) water will do more to alleviate it than 
either the continual sucking of ice or the drinking of effervescing waters. 
There is no reason for withholding an occasional draught of cold water 
if the patient long for it. If an enema fail to afford adequate relief to 
the bowels there need be no hesitation in administering a full dose of 
castor oil (the best of all aperients for the purpose if it can be retained), 
calomel, or magnesium sulphate. 

The state of the pulse, which in peritonitis is ordinarily a much truer 
guide to the condition of the patient than the temperature, will indicate 
when stimulants are needed. If the pulse show signs of flagging — that 
is of becoming thin, feeble, and intermittent — brandy or whisky should 
be given in defined and measured doses diluted with five or six times 
the quantity of water, and the effect carefully watched with a view to 
the increase or diminution of the dose as may be required. Stimulants 
should not be allowed, however, to take the place of food, but should be 
given as far as possible with food. Any tendency to collapse, indicated 
by coldness of the extremities, sunken features, flickering pulse, and sub- 
normal temperature, should be further combated by the application of 

2l 



514 SYSTEM OF GYNECOLOGY 

hot water bottles and tlie subcutaneous injection of strychnia. Of still 
greater importance is it to bear in mind the intensely depressing effect 
of intestinal distension, and to adopt means for enabling the patient from 
time to time to expel accumulated flatus. Nothing ansAvers the purpose 
so well as small soap-and-water clysters, which, if necessary, may be fre- 
quently repeated. The introduction of a soft india-rubber rectal tube is 
also often of great service ; the tube may be left in for a quarter of an hour 
at a time if its presence is not a serious annoyance to the patient. Turn- 
ing the patient on to her side is another, sometimes singularly effectual, 
means of assisting in the passage of flatus. 

Surgical. — Surgical measures are not often called for during an acute 
attack of pelvic peritonitis. When, however, Douglas' pouch is tense from 
fluid distension, forming a swelling more or less globular in shape, and en- 
croaching both on the vagina and rectum, there can be no hesitation as 
to the propriety of making an opening through the vaginal roof. Even 
should the inflammatory effusion prove to be serous only, the mere removal 
of tension will give great relief. If, on the other hand, the swelling prove 
to have been an intraperitoneal abscess, such timely interference will 
not only afford immediate relief to the more urgent symptoms, but will 
prevent the bursting of the abscess into the rectum, with the possible 
results of incomplete evacuation and the establishment of a troublesome 
sinus. 

With this exception it is usually wise to defer surgical intervention 
until the acute symptoms have subsided, and until an opportunity has 
been afforded of making a thorough bimanual examination, and of arriving 
at as near an approach to a correct diagnosis as the circumstances of the 
case permit. If the attack is the first the patient has had, and if the 
swelling, usually to be found in one or both posterior quadrants of the 
pelvis, be of so moderate a size as not to be incompatible with the existence 
of a non-purulent inflammation of the uterine apjjendages, the case is 
obviously not one in which operative interference should, for the moment 
at any rate, be recommended. If, on the other hand, the patient have 
had similar attacks previously, and if the swelling have attained such 
dimensions as to make it fairly certain that in the midst of it there is 
either an occluded and distended Fallopian tube or an ovary enlarged by 
cystic growth, the indications for the removal of the disease are perfectly 
clear. Such a mass, with a history of recurrent attacks of peritonitis, 
almost invariably means the presence of pus ; and where pus is there 
is no remedy worthy of the name except such as is offered by surgery. 
Between these two extreme instances there are, of course, cases present- 
ing all gradations ; and it is impossible to lay down detailed rules as to 
the conditions that justify operative measures and those that do not. 
Every case must be decided on its own merits, and according to the class 
of life to which the patient belongs. A woman from the labouring class 
cannot afford to spend several months of her life as an invalid, if there 
be a quicker way to recovery ; whereas one who, with ample means, has 
no necessity for leading an active life, will be perfectly justified in not 



PELVIC INFLAMMATION 515 

submitting to operation until treatment by prolonged rest has been 
thoroughly carried out and has failed to effect a cure. 

When operation has been decided upon, the method of operating still 
remains to be determined. Abdominal section, being the older and more 
generally adopted method, will be first described. An aperient having 
been administered on the previous day, and an enema early in the morning 
of the day of operation, and the skin of the abdominal wall having been 
thoroughly di sinf ected in the manner usual before all abdominal operations, 
the patient is placed on the operating table either in the ordinary or in 
the Trendelenburg position (the latter affording the operator a better 
view of the pelvic contents), and an incision from 21 in. to 3 in. long is 
made in the middle line, ending about an inch above the summit of the 
symphysis pubis. The operator must be alive to the possibility of adhe- 
sions between the intestine and the under surface of the anterior abdominal 
wall, and he must proceed carefully as he approaches the peritoneal cavity. 
Usually, on opening the cavity, the omentum is found drawn down so as 
to cover in the contents of the pelvis anteriorly, and to have contracted 
adhesions to the peritoneum as it becomes reflected on the anterior abdom- 
inal wall, as well as on the uterus and other pelvic viscera. The first 
step is to separate these adhesions sufficiently to allow the omentum (and 
any coils of small intestine which may have become adherent to it) to be 
drawn upwards, or to one side, so as to expose the matted contents of the 
pelvis behind it. Guidedchiefly,if not indeed entirely, by the sense of touch 
(unless the patient be in the Trendelenburg posture, when he may be aided 
in his manipulations by the sense of sight), the operator now endeavours, 
with the tips of the first two fingers of his left hand, to enucleate the 
diseased uterine appendages from their adherent surroundings. His first 
landmark is the body of the uterus, which is sometimes free and some- 
times implicated in the adherent mass. In the latter case identification 
may be difficult, and it maybe necessary for an assistant to pass one or two 
fingers into the vagina and to elevate the uterus by pressure on the cervix. 
When the fundus uteri has thus been identified, the Fallopian tube (on 
the diseased side if only one side is affected) is to be traced outwards 
from the uterine cornu, and made to serve as a guide in searching for the 
planes of adhesion. If the Fallopian tube, which is often normal in size 
and consistence for the first inch or so, turns quickly backwards and 
becomes lost in the adherent mass, the safest way of commencing the 
separation of adhesions is by keeping the fingers close to the posterior 
surface of the uterus, and tracing the adherent mass downwards into 
Douglas' pouch. During the manipulations necessary in separating the 
mass from the walls of the pouch, including the anterior wall of the rec- 
tum, it is often desirable for an assistant to pass a forefinger into the 
rectum ; partly to facilitate the separation by steadying the bowel, and 
partly to enable the operator to know exactly where the bowel is and 
when he is in dangerous proximity to it. The separation of adhesions in 
Douglas' pouch is very often the most difficult part of the operation. 
When this has been effected the tips of the fingers are to be insinuated 



5i6 SYSTEM OF GYNECOLOGY 



beneath the mass, and the separation is to be continued posteriorly from 
below upwards. When the mass has been cleared from its posterior and 
inferior attachments to the uterus and to the uterine appendages of the 
opposite side, there still remain the adhesions to the back of the broad 
ligament which has usually become more or less so folded over the dis- 
eased parts as to form a deeply concave surface on what is, anatomically, 
its posterior aspect. It is from this concave surface that the mass has 
now to be separated in order to allow of its being brought up into view, 
and to permit of the transfixion of the broad ligament below it. The 
detachment should be effected by working from below upwards, and 
should be continued until all adhesions have been separated and the ovary 
and tube remain attached to the uterus and broad ligament by their 
anatomical connections only. The pedicle is tied and divided as in the 
operation of removal of the normal uterine appendages for uterine 
myoma. The appendages of the other side are now to be examined : 
if they are found diseased they should be removed ; if merely adherent 
the operator may content himself with separating adhesions. 

It often happens that during the manipulations just described there 
is an escape of pus. This is not necessarily due to any fault of the 
operator; it is usually the inevitable result of separating adhesions 
around the mouth of a suppurating and adherent tube, or of enucleat- 
ing a suppurating and adherent ovary w^hose wall is ulcerated and on 
the point of bursting. Fortunately, it is only when the pus is unusu- 
ally virulent that serious harm results from its escape. 

Sometimes it becomes obvious during the operation that persistence 
in the separation of adhesions would expose the patient to unjustifiable 
risk, either from unduly prolonging the operation, or from the danger of 
injuring the surrounding viscera. This is specially apt to occur in the 
case of suppurating ovarian cysts. The operator will find, however, that 
the cases in which it becomes necessary for him to desist from attempts 
at entire removal, and to content himself with emptying and draining the 
suppurating cavity, will diminish as his experience increases. The separa- 
tion of adhesions to parts of the intestine other than the rectum should 
be undertaken, whenever practicable, with the parts well in view ; and 
any injury sustained by the bowel during the process should be repaired 
at once. One of the chief risks of the operation is the liability of mis- 
taking thickened and adherent intestine for an inflamed Fallopian tube. 
The risk is best obviated by rigidly following the rule of identifying the 
tube by tracing it from its uterine end outwards, before commencing to 
separate adhesions. 

Whenever it is obvious that the ovary, notwithstanding the adhesions 
with which it is surrounded, is itself free from disease, it is good practice 
not to remove it. If even one ovary can be preserved it will prevent the 
arrest of the menstrual function, and so will save the patient from the 
discomforts that attend the premature induction of the menopause. 

The rule to remove only such parts as are diseased is a sound one : 
but in the case of tubal disease, where the gross lesion is limited to one 



PELVIC INFLAMMATION 517 

side, the apparently healthy tube of the opposite side should always be 
carefully examined. If pus exude from it on pressure the proper course 
is to remove the tube, notwithstanding the absence of thickening of its 
walls or other obvious sign of disease. It not unfrequently happens 
that the tube opposite to that which is chiefly affected, though not 
actually diseased, has become transformed into a retention cyst (hydro- 
salpinx) by occlusion of its abdominal ostium by peritonitis. In such a 
case either the tube should be removed, or its contents should be evacuated 
and a portion of its wall excised. 

Every care should be taken during this operation to avoid opening 
the general peritoneal cavity, if it be possible. The toilet of the peri- 
toneum, after the operation has been completed, should be effected, if 
necessary, by plentiful douching with hot water (temp. 105° F.) rather 
than by the vigorous use of the sponge or any of its substitutes. The 
insertion of a drainage tube is a point that must be left to the judgment 
of the operator in each individual case. The use of the drainage tube 
(or strip of gauze which is its equivalent) tends to diminish in frequency 
as experience increases. 

With regard to other matters that concern the technique of this 
operation, in common with that of abdominal operations in general, the 
reader is referred to the articles on pelvic surgery. One point, how- 
ever, in connection with the closing of the abdominal incision may be here 
mentioned. It has been found greatly to lessen the risk of hernia if, 
before tying the silk-worm gut sutures that pass through the entire 
thickness of the abdominal wall, the edges of the sheath of the rectus 
muscle are brought carefully into apposition by means of a continuous 
catgut suture. This is preferable to suturing the abdominal wall in 
layers, which method is apt to leave, between the various layers, interspaces 
that facilitate the lodgment of serous and other inflammatory effusions. 

The after-treatment differs in no respect from that of other abdominal 
operations. 

Within the last few years another method of operating in these cases 
has come into rivalry with that by abdominal section. This newer 
operation — first proposed and carried out by Pean in 1886, and since 
popularised, though in the face of much opposition, by the earnest 
advocacy of Segond and others — consists in the removal of the uterus 
through the vagina, supplemented or not, according to circumstances, by 
the removal of the diseased uterine appendages. It is argued by the 
supporters of this method that the return of pelvic pain and tenderness, 
met with in certain cases after the removal of diseased uterine apx^endages 
by abdominal. section, is due to the fact that the uterus, the original 
source of all the trouble, is left behind. By the removal of the uterus 
through the vagina in the first instance, it is maintained that not only 
is the attack made upon the original seat of the inflammation, but that 
so excellent a channel is established for drainage that abscess cavities, 
whether in the tubes or ovaries, or amongst the peritoneal adhesions, 
can be readily evacuated. Thus, in many cases, it is said to be un- 



5i8 SYSTEM OF GYNECOLOGY 

necessary to proceed to the removal of the diseased appendages them- 
selves. The operation, though its precise position and value have not 
yet been settled, has now been adopted by a sufficiently large number 
of influential operators to have established for itself a claim to the 
serious consideration of all who are interested in the advance of gynae- 
cological surgery. 

The first steps of the operation are much the same as in the ordinary 
operation of vaginal hysterectomy. The patient is prepared by the 
administration, for several days before the operation, of vaginal douches 
of solution of corrosive sublimate 2"oVoj ^^^ ^7 ^^ usual purge and 
enema a few hours before the operation is to take place. 

At the time of operation the patient is placed in the lithotomy 
position, and four large vaginal retractors (preferably those of Pean) are 
introduced — one anteriorly, one posteriorly, and one on each side. An 
assistant on the left side takes charge of two of these, and one on the 
right of the other two. The cervix is drawn down by means of a 
volsella and a circular incision made, the incision being nearer the 
OS externum anteriorly than posteriorly, where it may be half an inch 
above it. In order to give additional room two lateral incisions are now 
made in the vaginal wall, each about two-thirds of an inch long, running 
outwards from the circular incision and parallel with the lower border 
of the broad ligament. The tip of the anterior retractor being now 
placed in the wound, the bladder and cervix are separated, as far as is 
practicable, by means of successive snips with the blunt-pointed curved 
scissors. The scissors are held with the concavity of the curve towards 
the uterus, so as to avoid the bladder and keep as near to the uterus 
as possible. The attachments of the cervix posteriorly are now divided, 
partly by the scissors and partly by the finger, a retractor again being 
used to pull back the liberated tissue. The next step is to secure by 
ligature or forceps the lowermost inch of the broad ligament including 
the uterine artery. This is done by gliding the forefinger of the left 
hand outward over the anterior surface of the cervix towards the base 
of the broad ligament, pushing aside the ureter and penetrating between 
the anterior peritoneal fold and the ligament proper. The same having 
been done behind, the lowermost inch of the broad ligament is grasped 
between the fingers and secured by ligature or clamp-forceps. The 
attachments of the ligament to the uterus are now divided, close to the 
uterine tissue, to a height corresponding with that of the section secured. 
The opposite side is dealt with in the same way. The cervix is then slit 
up on each side so as to divide it into two flaps, anterior and posterior. 
The posterior flap is cut off, the anterior is seized with strong forceps 
and drawn well down, and a further separation of the bladder is effected. 
The stump having been secured against retraction by seizing it with a 
'' bullet-traction " forceps above the line of amputation, the anterior 
cervical flap is now cut off. The next stage of the operation consists in 
the removal piecemeal — by morcellation as it is technically termed — of 
the anterior wall of the uterus. The stump being pulled down by means 



PELVIC INFLAMMATION 



519 



of a traction forceps inserted into each, side, the uterus is still further 
separated from the bladder, and small pieces, extending through the 
entire thickness of the anterior uterine wall, are removed with scissors 
or knife by a succession of vertical or oblique sections in the middle line. 
The forceps are successively re-inserted higher up, the uterus is further 
drawn down and set free, and the morcellation is repeated, until the 
peritoneal cavity is reached. The fundus uteri now descends sufficiently 
to allow of its being hooked down by the operator's finger and everted. 
Such adhesions as exist posteriorly can be seen and separated, and the 
upper portion of each broad ligament is then secured by one or more 
ligatures or by forceps, and the separation of the uterus completed. To 
facilitate this part of tlie operation some surgeons divide the uterine 
stump longitudinally and deal with each half separately. 

The advantage of morcellation is "that the operator sees exactly 
what is being done, step by step." If, during the separation of adhesions, 
pus is seen to escape, the opening into the pus cavity is enlarged by the 
operator's finger, the cavity is washed out, and the operation resumed. 
When it is possible to separate the adhesions, the inflamed uterine 
appendages should be gently pulled down into the vagina, ligatured or 
clamped, and removed. If the tubes present themselves as large coils 
distended Avith pus, the surrounding parts are protected by means of 
small mounted sponges, and the tubes are opened with the knife in 
such a way that the contents escape into the vagina without soiling the 
peritoneum. The edges of the opening are seized with forceps to guard 
against retraction, and the cavity is irrigated with solution of corrosive 
sublimate. The tubes should then, if possible, be removed by enuclea- 
tion with the fingers. If this be found impracticable, they may be left 
to drain and undergo atrophy. Search should be made with the fingers 
for any out-lying abscesses, in order that they may be opened and 
drained. Where the inflamed appendages are situated high up, and are 
so densely adherent that they cannot be drawn down into view, their 
separation has to be effected, if effected at all, by the aid of the sense 
of touch, as in the older operation. 

Many modifications of the operation have been introduced, but the 
above account embraces the leading features of the method practised by 
the most successful operators. 

The dressings of the Avound are the same as in ordinary vaginal 
hysterectomy. Iodoform gauze should be packed lightly into any pus 
cavities that have been left, and removed with the tampons in six days. 
If clamps have been used, they must be removed in forty-eight hours. 
An enema is administered on the third day, and from that time nour- 
ishing food is given.^ 

It is claimed for this operation that, whilst its mortality is no higher, 

1 The above account is for the most part abridged from the admirable description of 
the operation contained in a paper by Dr. Edgar Garceau, entitled " Vaginal Hyster- 
ectomy as done in France," in the American Journal of Obstetrics, March 1895, to which 
and to the writings of Segond. Richelot, Jacobs, Leopold, A. Martin, and Landau, the 
reader is referred for fuller details. 



520 SYSTEM OF GYNECOLOGY 

and perhaps even less higli than that of abdominal section (undertaken 
for the same object) it enables the operator to see better what he is 
doing ; it is attended with less shock ; it ensures far better drainage ; 
and it does away with the liability to ventral hernia and to troublesome 
sinuses in the line of incision. It is also urged that inasmuch as the 
uterus was the seat of the original lesion, and may become the source 
of re-infection, its removal must be a distinct gain. 

The validity of most of these claims need not be questioned ; but 
there are some points in the essential feature of the operation — namely, 
the removal of the uterus — that do not appear to have received ade- 
quate consideration. To remove an organ because its lining membrane 
is inflamed can scarcely be accepted as coming within the domain of 
legitimate surgery, unless it can be shown (1) that the inflammation does 
not tend to subside spontaneously ; (2) that there is no other efficient 
means of treatment, and (3) that the retention of the organ is likely to 
be a source of greater danger than the operation undertaken for its 
removal. In all these respects the uterus is in a different position from 
the Eallopian tube, and an operation that would be perfectly justifiable 
in the case of an inflamed tube would not necessarily be justifiable in the 
case of an inflamed uterus. The uterus has, in its cervical canal, a 
natural outlet for its morbid secretions. The tube has no such natural 
outlet ; its morbid secretions either become pent up in the closed tube, 
or escape through the abdominal ostium into the peritoneum. In either 
case they are retained within the body, and hinder the natural process of 
recovery, which, in the case of the uterus, is carried on without any such 
impediment. Again, in regard to accessibility for local treatment, the 
uterus and the Fallopian tube are on a totally different footing ; the 
interior of the uterus is easily within reach, its lining membrane can be 
swabbed, douched, and curetted at will. The Fallopian tube, on the 
contrary, is beyond the reach of all these therapeutic measures. We 
have no means, such as we have in the case of the uterus, of facilitating 
the natural process of cure by local treatment. 

As to the possibility of the uterus becoming a source of re-infection, 
it must be remembered that although it is of course possible, after the 
removal of the appendages, for the uterus to re-infect the peritoneum and 
become a source of fresh mischief, there is no actual evidence that this 
has happened. The danger is purely hypothetical. On the other hand, 
there is abundant evidence to show that the uterus may become per- 
fectly sound. Thus, instances are by no means infrequent in which 
removal of the inflamed appendages for disease limited to one side has 
been followed by pregnancy, the best proof the uterus could give of the 
soundness of its condition and the completeness of its cure. 

The conclusion to be drawn from these considerations is that the 
indiscriminate removal of the uterus in all cases of operation for 
inflammatory disease of the appendages is unjustifiable, and that the 
vaginal operation ought, at any rate, never to be undertaken unless it 
be certain that the appendages of both sides are seriously involved in 



PELVIC INFLAMMATION 521 

the disease, and that conception and pregnancy would be practically 
impossible. 

Even apart, however, from this fundamental question of the propriety 
of removing the uterus, the admitted advantages of the newer operation are 
not without counterbalancing disadvantages. The operation is one of 
great difficulty and cannot always be completed. It sometimes happens, 
indeed, that, after the uterus has been extirpated, it is necessary to 
perform abdominal section in order to remove the adnexa. Again, there 
is greater danger than in the abdominal operation of injuring the bladder 
and the ureter, and probably also the rectum. It has been said that 
another of the special risks of the vaginal operation is haemorrhage ; but 
this is a danger to be eliminated by an improved technique. 

If, however, the vaginal operation proves in its results to be superior 
to the abdominal operation, no merely theoretical considerations ought 
to prevent or will prevent its gradual adoption. The time has not yet 
arrived for pronouncing a final judgment on the merits of the two 
operations, or (if, as seems likely, both of them eventually find a 
legitimate and permanent place in operative gynaecology) for drawing 
up a formal and authoritative statement of the respective indications 
for the one operation or the other. In the meantime there can be no 
doubt that the vaginal operation is at present growing in favour, and that 
amongst recent converts are to be found men whose recognised sobriety 
of judgment compels attention to their views. 

There still remains another class of cases in which operative 
interference is occasionally attended with signal benefit, that, namely, 
in which much suffering and more or less disablement are caused not by 
definite inflammatory changes in the tube or ovary, but by peritonitic 
adhesions. The salpingitis that originally started the pelvic peritonitis 
may have subsided so that there may no longer be any definite swelling 
in the sides of the pelvis, and yet the peritonitis may have left the pelvic 
viscera matted together by adhesions of such a kind as to condemn the 
patient to a life of invalidism. In a large number of these cases the 
uterus is fixed in a position of retro-displacement. Under these circum- 
stances separation of the adhesions and permanent restoration of the 
uterus to its normal position often succeed in removing the symptoms 
and restoring the patient to health. 

As in the operation for the removal of the diseased appendages, there 
are two principal methods of operating from which to choose ; namely, 
abdominal section and operation per vaginam. In the former, an incision 
of sufiicient length to admit of two fingers is made in the middle line, 
terminating an inch above the pubes. The uterus and its appendages 
are carefully liberated from their adhesions, and the uterus, having been 
lifted up into its normal position, is secured in that position either by 
suturing the anterior surface of the uterus to the abdominal wall (ventro- 
fixation) or by inserting a Hodge's pessary into the vagina. 

In a certain small number of cases in which there are no formidable 
adhesions between the body of the uterus and the bladder, and in which 



522 SYSTEM OF GYNAECOLOGY 

the posterior adhesions are not very firm or very extensive, the separation 
of the adhesions and the fixation of the uterus in its normal position 
can be accomplished per vaginam by Dtihrssen's operation of anterior 
colpotomy. This operation consists in drawing down the cervix, 
separating the bladder, and dividing the utero-vesical fold of the 
peritoneum. Access to the peritoneal cavity is thus obtained through 
the anterior vaginal fornix.^ Two or three fingers are then passed up, 
the fundus is seized and drawn forwards, adhesions are carefully broken 
down, the pelvic viscera are liberated, and, finally, the uterus is secured 
in its normal position of anteversion by the procedure known as vaginal 
fixation. At the close of the operation the peritoneal and vaginal wounds 
are closed by means of continuous catgut sutures. 

The separation of peritonitic adhesions in the pelvis can occasionally 
be effected, without operation, by the manipulative methods associated 
respectively with the names of B. S. Schultze and Thure Brandt. But 
these methods have not found favour in this country, nor are they likely 
to do so. The objections to them are too obvious to need discussion. 

Charles J. Cullingwokth. 



REFERENCES 

1. Anderson, W., and Makins, G. H. " The Planes of Subperitoneal and Subpleural 
Connective Tissue, with their Extensions," Journal of Anatomy and Physiology, 
vol. XXV. part 1, Oct. 1890, p. 78. — 2. Aran, F. A. Lemons cliniques snr les maladees 
de I'uterus et ses annexes, pp. 569-750. Paris, 1858. — 3. Bandl, L. " Krankheiten 
der Tuben, der Ligaraente, des Beckenperitoneum und des Beckenbindegewebes," 
Deutsche (Jhirurgie ; herausg. von Billroth und Luecke, Lieferung 59. Stuttgart, 
1886. — 4. Bernutz, G., and Goupil, E. Clinical Memoirs on the Diseases of Women. 
Transl. and edit, by A. Meadows, 2 vols. New Syd. Soc. Lond., 1866-67. — 5. Byford, 
H. T. " Inflammatory Lesions of the Pelvic Peritoneum and Connective Tissue," 
Clinical Gynsecology by American authors. Edit, by Keating & Coe, vol. i. Edin. 1895, 
pp. 400-460. —6. Champneys, F. H. "On the Removal of the Uterine Appendages," 
St. Bartholomew's Hosp. Reports, vol. xxix. for 1893, pp. 45-G2. — 7. Cullingworth, C. 
J. "The Etiological Importance of Gonorrhoea in Relation to some of the more common 
Diseases of Women," Brit. Med. Journ. July 20, 1889. — 8. Ibid. "On the Differential 
Diagnosis of Pelvic Inflammations in the Female," Brit. Med. Journ. Dec. 27, 1890. — 
9. Ibid. " The Value of Abdominal Section in certain Cases of Pelvic Peritonitis," 
Trans. Obst. Soc. Lond. vol. xxxiv. for 1892, pp. 254-429. — 10. Ibid. "On Pelvic 
Peritonitis in the Female, and the Pathological Importance of the Fallopian Tubes in 
Connection therewith," Brit. Med. Journ. Aug. 12, 1893. — 11. Ibid. "On Pelvic 
Abscess," Birmingham Med. Review, Nov. 1893. — 12. Ibid. "Three Cases of Pelvic 

1 The operation will be found described in detail in Diihrssen's Manual of Gynseco- 
logical Practice, translated by Taylor and Edge. London, Lewis, 1895, pp. 54 et seq. 
Tliough it finds its most frequent and useful application in the cases above referred to, 
the operation can be utilised for many other purposes, such, for example, as the removal 
of small pedunculated subperitoneal myomata, of small and not too adherent tumours of 
the ovary, of tubal gestation-sacs, and of diseased uterine appendages when these can be 
drawn into the vagina. The advantages of this over the abdominal operation are that it 
is less dangerous, and that, owing to the position of the scar, adhesions and hernia of the 
intestine and omentum are avoided. Its scope, however, is limited, inasmuch as it is 
only applicable to cases where the cervix can be drawn down to the vaginal entrance, 
and where, if there is any mass to be removed, the size of the mass does not much, if at 
all, exceed that of the fist. 



PELVIC INFLAMMATION- 523 

Inflammation attended with Abscess of the Ovary," Trans. Obst. Soc. Loncl. vol. xxxvl. 
for 189J:, pp. 277-296. — 13. Gushing, E. W. "The Pathology and Diagnosis of so- 
called Pelvic Cellulitis," Annals of Gynsecologi/, Boston, U. S. A. March 1889. — 14. 
Delbet, p. Des suppurations pelvienaes chez la fenime. Paris, 1891. — 15. Doran, 
A. " The Treatment of Chronic Disease of the Uterine Appendages," Trans. Med. Soc. 
i/OTid. vol. xiv. London, 1891, pp. 239-251. — 1(3. Ibid. "The Relations to each other 
of Inflammation of the Endometrium, Fallopian Tube, Ovary, and Pelvic Peritoneum," 
Trans. Obst. Soc. Lond. vol. xxxii. for 1885, p. 164. — 17. Duncan, J. Matthews. 
A Practical Treatise on Perimetritis and Parametritis. Edin. 1869. — 18. Ibid. 
'"On Haemorrhagic Parametritis," Trans. Obst. Soc. Lond. vol. xxix. for 1887, pp. 
191-197. — 19. Duncan, W. "On Chronic Diseases of the Uterine Appendages," 
Trans. Med. Soc. Lond. vol. xiv. London, 1891, pp. 214-239. —20. Griffith, W. S. 
A. "Perimetric Abscess," Trans. Obst. Soc. Lond. vol. xxiv. for 1882, p. 299; "Retro- 
Uterine Perimetric Abscess," Ibid. vol. xxv. for 1883, p. 18 ; " Serous Perimetritis," Ibid. 
vol. xxvii. for 18S5, p. 1(58: "Anterior Perimetritis and Anterior Parametritis," Ibid. 
vol. xxix. for 1887, p. 147; "Parametritis dextra," Ibid. vol. xxx. for 1889, p. 5. — 21. 
Ibid. "Perimetritis and Parametritis," St. Bai'thol. Hosp. Reports, vol. xvi. for 1880, 
pp. 285-305. — 22. Ibid. "A Fatal Case of Perimetritis," Ibid. vol. xviii. for 1882, 
pp. 291-296. — 23. Herman, G. E. "Lectures on Parametritis," Clinical Journal, 
vol. vi. Nos. 9, 10, 11, 12. London, 1895.— 24. Jones, Mary A. Dixon. "Removal 
of the Uterine Appendages," Med. Record. New York, Aug. 21, 1886. — 25. Keiller, 
W. "Pelvic Peritonitis and Cellulitis." Amer. Journ. of Obst. vol. xxviii. No. 3. 
New York, 1893. — 26. Lewers, A. H. N. "Double Pyosalpinx -v^-ith Rupture of the 
Tubes," Trans. Obst. Soc. Lond. vol. xxvii. for 1885, p. 298.-27. Ibid. "Note on 
the Post-mortem Appearances of a Phlegmon of the Broad Ligament," Ibid. vol. xxx.' 
p. 7. — 28. M'Clintock, A. H. Clinical Memoirs on Diseases of Women. Dublin, 
18(53. — 29. Macdonald, A. "Latent Gonorrhoea in the Female Sex, with special 
Relation to the Puerperal State," Obst. Journ. Gt. Brit. vol. i. 1873, p. 254 (Abstract). 
— 30. Martin. A. " Ueber Tubenerkrankung," Zeitschr. fiir Geburtshiilfe und 
GyndJcolofjie, Bd. xiii. Stuttg. 1886, pp. 298-311. — 31. Ibid. " Colpotomia anterior," 
Monatsschrift fiir Geburtshiilfe and Gynlikologie. Berl. Aug. 1895. — 32. Ibid. Die 
Krankheiten der Eileiter, Leipz. 1895. — 33. Maury, R. B. "How shall we treat our 
Cases of Pelvic Inflammation?" Amer. Journ. of Obst. vol. xxiv. No. 1. New York, 
1891. — 34. Ibid. "The Present State of our Knowledge of Pelvic Inflammation, with 
Special Reference to the Treatment of Pelvic Abscess," Amer. Journ. of Obst. vol. xxviii. 
No. 6. New York, 1893. — 35. Menge, K. "Ueber die gonorrhoische Erkrankung der 
Tuben und des Bauchfells," Zeitschr. fiir Gebjirtshiilfe und GyyiUkologie. Band xxi. 
Stuttg. 1891, pp. 119-159.-36. Monprofit. Etude chirurgicale sur les inflammations 
des organes genitaux internes de la femme : salpingites et ovarites. Paris, 1888. —37. 
Noeggerath, E. Die latente Gonorrhoe im iveiblichen Geschlecht. Bonn. 1872. — 38. 
Ibid. "Ueber latente und chronische Gonorrhoe beim weiblichen Geschlecht," 
Deutsche medicin. Wochenschrift, 1877, No. 49. Berlin. — 39. Polk, "W. M. "A 
Study of Peri-uterine Inflammation in its Relation to Salpingitis," Trans. Assoc. Amer. 
Physicians, vol. i. Philad. 1886, pp. 145-169. — 40. Ibid. "Inflammations of the 
Uterine Appendages and Peritoneum," Clinical Gynecology by American Authors. 
Edit, by Keating and Coe, vol. i. Edin. 1895, pp. 3.3.5-382.-41. Pozzi, S. Traite 
de gynecologie,2me edit. — 42. Rosthorn, A. V. " Vierzig Falle von Abtragung und 
Entfernung der Anhiinge der Gebarmutter," Archiv fiir Gynlikologie, Bd. xxxvii, Berl. 
1890, pp. 337-419. — 43. Sanger, IVLvx. "Ueber die Beziehungen der gonorrhoischen 
Infektion zu puerperal-Erkrankungen," Verh. derdeutsch. Gesellschaft fiir Gynakologie. 
Leipz. 1886. — 44. Ibid. Die Tripperansteckung beim iceiblicheyi Geschlechte. Leipz. 
1889. — 45. Segond, P. De Vhysterectomie vaginal dans le traitement des suppurations, 
pelviennes. Paris, 1891. — 46. Sinclair, W. Japp. On Gonorrhteal Infection in 
Women. London, 1888. — 47. Schmitt, A. " Zur Kenntniss der Tnbengonorrhoe," 
Archiv fiir Gyndk. Band xxxv. Berlin, 1889, pp. 162-186.-48. Tait, Law^son. 
" On the Treatment of Pelvic Suppuration by Abdominal Section and Drainage," Med. 
Chir. Trans, vol. Ixiii. for 1880, pp. 307-316.-49. Ibid. "Recent Advances in 
Abdominal Surgery," Trans. Int. Med. Cong. 1881, vol. ii. p. 228. London.— 50. 
Ibid. Diseases of Womeii and Abdominal Surgery, vol. i. Leicester, 1889. pp. 333- 
435. — 51. Ibid. "A Discussion of the General Principles involved in the Operation 
of Removal of the Uterine Appendages," New York Med. Journ. Nov. 20. 1886. — 52. 
Targett, J. H. "Acute Suppuration and Sloughing of Ovaries after Parturition," 
Trans. 06s^. 5oc. Lo».d. vol. xxxvii. for 18!)5, p. 216.— 53. Taylor, J. W. "Clinical 



524 SYSTEM OF GYNECOLOGY 

Lecture on Pyosalpinx, with Remarks on the old faith and the new regarding 
Parametritis and Perimetritis," Lancet, 1889, vol. ii, p. 581. — 54. Terillon, O- 
•Salpingites et ovarites. Paris, 1891.— 55. Treves, F. Peritonitis. London, 1894. 
— 56. ViRCHOw, R. " Ueber puerperale diffuse Metritis und Parametritis," Archiv 
fur path. Anat. und Physiol, herausg. v. R. Virchow, Bd. xxiii. Berl. 1862, pp. 415- 
427.-57. West, C. Lectures on Diseases of Wome7i, 4th edit, by J. Matthews 
Duncan. Lond. 1879, pp. 421-452.-58. White, J. W. "Oophorectomy in Gonor- 
rhoeal Salpingitis," B)^it. Med. Journ. Feb. 19, 1889.-59. Williams, Sir J. "On 
Serous Perimetritis," Trans. Ohst. Soc. Lond. vol. xxvii. for 1885, pp. 169-181.-60. 
Zweifel, p. " Ueber Salpingo-Oophorektomie," Archiv fUr Gyndk. Band xxxix. Hft. 
3, Berl. 1891, pp. 353-392. 

C. J. c. 



PELVIC HEMATOCELE 

Definition and Synonyms. — An encysted tumour formed by the ex- 
travasation of blood from some part of tlie generative organs into the 
pelvic tissues in the immediate neighbourhood of the uterus. 

Much discussion has taken place concerning the true definition of 
pelvic hsematocele and the pathology of it. Thus it has received the 
various appellations — ''retro-uterine heematocele," "peri-meterine or 
peri-uterine hsematocele," " hsematoma," " pelvic thrombus," and the like. 
The term "pelvic hsematocele" is the most comprehensive, as it may be 
employed to include all forms of tumours in the true pelvis formed by 
extravasated blood, irrespective of their exact relation to the uterus, and 
of the theories of pathologists ; premising always, of course, that they 
have their origin in the reproductive organs. 

General Pathology. — Introductory. — It is comparatively within recent 
years that attention has been called to the subject of pelvic haematocele, 
and that it has found a place in medical nomenclature. 

Some short account of the earlier recorded cases, and of the successive 
steps taken to investigate their nature, is essential to the elucidation of 
its pathology. The earliest instances in which the recorded facts leave 
no doubt as to the identity of the disease occurred in the practice of 
E-ecamier in the Hotel-Dieu in Paris. One of these was published in the 
Lancette Frangaise, July 21st, 1831, under the title " Tumeur sanguine 
du Bassin." A woman, 28 years of age, after a miscarriage, had a large 
tumour in the true pelvis behind the uterus, which projected into the 
vagina. Kecamier, believing it to be an abscess, opened it ; but, instead 
of pus, dark, half-coagulated blood escaped from the aperture. In 
1841 M. Bourdon, in the Revue medicale, described the physical signs 
of blood tumours situated in the peri-uterine cellular tissue of the 
pelvis ; and somewhat later Yelpeau in his Memoire sur les cavites doses 
published additional cases, and was evidently acquainted with the true 
character of these affections. Other cases were reported later by 



PELVIC HALMATOCELE 



525 



Bernutz and Piogy. Bernutz claimed priority in having pointed out 
in 1848 the relation between pelvic blood tnmours and disturbance of 
the menstrual function ; but in his opinion the honour of having first 
discovered true haematocele belongs to Euysch in 1691. 

Be this as it may, the first clear and intelligible account of the 
affection was published in France by IS^elaton, the distinguished 
Professor of Clinical Surgery in Paris ; and to him belongs the merit of 
bringing the affection into prominence and giving it a permanent place 
in our nosology. It was in 1850 that Nelaton drew the attention of 
his class to the occasional occurrence of fluctuating tumours situated 
between the uterus and rectum, which on being laid open were found to 
contain extra vasated blood. Prom the position of the tumour he gave 
it the name of " retro-uterine hsematocele " ; a title still applied to it by 
some authors, but too limited in its definition : further investigation 
has demonstrated that, besides the posterior aspect of the uterus, 
haematocele is found in other localities in the pelvis. 

In 1851 M. Nelaton made retro-uterine haematocele the subject of 
Clinical Lectures, and these were subsequently published in the Gazette 
des Iwpitaux. The description there given is clear and precise ; and 
without detracting from the merits of those who preceded him, it may 
be said that until the appearance of ISTelaton's Clinical Lectures the sub- 
ject was absolutely unknown to the majority of medical practitioners 
in Prance and elsewhere. Even in 1850 the celebrated surgeon 
Malgaigne attempted to enucleate a supposed fibroid tumour of the 
uterus, which proved to be an encysted collection of blood 5 the opera- 
tion was followed by fatal haemorrhage. 

The lectures of Nelaton having drawn attention to the subject, it was 
soon discovered that the disease in cjuestion was by no means so rare 
as might be supposed from the little which had been written upon it. 
Many contributions speedily followed. Among the first and best of the 
theses on haematocele was that of Vigues, a pupil of Nelaton ; and later 
followed those of Peuerly, Yoisin, and others. In 1860 Voisin pub- 
lished an octavo volume on Retro-uterine Hcematocele and N'on-encysted 
Extravasations of Blood in the peritoneal Cavity of the Pelvis ; and fur- 
ther contributions were made in Prance by Laugier, Pouget, Penerley, 
Puech, and Bernutz and Goupil ; in Germany by Virchow, Scanzoni, 
Braun, Herber, Crede, Breslau, Seyfert, and Olshausen. In Great 
Britain the subject received early notice in Dr. Tilt's Diseases of Women, 
and in lectures published by Dr. West and Sir James Simpson. Dr. 
Barnes especially drew attention to the frequency of the accident. A 
numerous array of instances were chronicled, and many observers wrote 
about it or made it the subject of discussion in debating societies. 
Among others may be mentioned Drs. M'Clintock, Matthews Duncan, 
Tuckwell, Meadows, and Madge. 

Haemorrhage into the pelvic cavity may take place in various posi- 
tions ; and it may issue into the peritoneal cavity, or outside and be- 
neath the peritoneum into the pelvic cellular tissue. Haemorrhage, 



526 SYSTEM OF GYNECOLOGY 

again, in the pelvis varies in amount and in diffusion. It may be so 
extensive as to give neither time nor opportunity for it to become en- 
cysted — the patient may die speedily from shock and loss of blood : in 
other cases it may be so small as to afford very indefinite indications of 
its presence. Further, blood extravasation into the pelvis may arise 
from a diversity of causes even in connection with the generative organs. 

Hence much controversy has taken place concerning the true definition 
of hsematocele. Under the name " retro-uterine hsematocele " ISTelaton and 
his followers grouped together all the varieties of blood tumour found 
posterior to the uterus or around it, irrespective of their causes. Voisin 
restricts the name to those cases in which the blood is extravasated into 
the peritoneal sac between the uterus and rectum ; and further, accord- 
ing to him, the result must be due to some accident of menstruation. 
Bernutz, one of the earliest and most authoritative writers on the sub- 
ject, insists that Nelaton's grouping is irrational, and that pelvic haem- 
orrhage is not a specific disease apart from that which caused it, but is 
simply a haemorrhage symptomatic of certain morbid conditions which 
ought to be the main object of pathological study. In his endeavour to 
define cases of true haematocele, Bernutz adduces the analogy between 
the tunica vaginalis in the male and the recto-uterine cul-de-sac in the 
female, — the only difference between the two being that the folds of 
peritoneum forming the tunica vaginalis are external to and shut off from 
the abdominal cavity in surrounding the testicle ; while in the female the 
analogous folds of peritoneum, subtending the two ovaries, together form 
an open sac communicating with the general peritoneal cavity. As, 
therefore, he Avould apply the name " haematocele " in the male to a col- 
lection of blood in the tunica vaginalis, he restricts it in the female to 
collections of blood in the retro-uterine pouch of the peritoneum ; and, 
in respect of their causes, to those blood tumours which arise from some 
accident of menstruation. It is obvious that this definition could not be 
accepted by many recent authors, who believe that ectopic gestation is 
the most frequent cause of hsematocele in all its forms. By authors 
generally, both in Great Britain and elsewhere, the term " hsematocele " 
in women is used in a wider and more comprehensive sense ; and in- 
cludes tumours formed by the extravasation of blood not only into the 
retro-uterine cul-de-sac of the peritoneum — although clinically this may 
be the most common — but also elsewhere around the uterus ; and more 
especially into the cellular tissue of the pelvis which lies outside the 
peritoneum. Even in France, the country to which we owe the largest 
amount of original work on this disease, the term '^ haematocele " is now 
used in this more comprehensive sense ; and Pozzi, one of the latest and 
best French writers on Gynaecology, adopts this description. 

Derangement of the menstrual function is recognised as a common 
and fertile source of pelvic haemorrhage, but other causes are not excluded. 
The late Dr. M'Clintock, in an able paper on this subject, remarks that 
he " cannot agree with Bernutz that to discover the existence of pelvic 
hsematocele constitutes only the half and the less important half of the 



PELVIC HEMATOCELE 527 

diagnosis ; on the contrary, it is, I should say, by far the most important 
half ; for if we overlooked the haematocele, and were cognisant only of 
the morbid condition from which it had arisen, what errors of prognosis 
and treatment might we not commit ? " As a practical fact, it may be 
pointed out that the treatment of effusions of blood into the pelvis must 
be influenced in a much greater degree by the rapidity, extent, and posi- 
tion of the extravasation, than by the pathological condition which caused 
them ; and although Bernutz is doubtless correct in his assertion that 
the sanguineous effusion is only a symptom and effect of some pre-ex- 
isting pathological condition — in the same sense as menorrhagia may 
be — yet all Bernutz contends for would be attained by bearing in mind 
that, like metrorrhagia or uterine haemorrhage, it may proceed from a 
diversity of pathological causes. 

Concerning the anatomical situation of pelvic hsematocele, again, much 
controversy has arisen. Voisin and Bernutz only admit those cases to 
be true haematocele in which the blood is poured into the peritoneal sac 
between the uterus and rectum. The instances in which blood is extrav- 
asated into the cellular tissue, around the uterus, and beneath and out- 
side the peritoneum, they regard as cases of " thrombus," akin to those 
blood tumours which are found occasionally in the external genitals in 
connection with the puerperal state, or produced by violence and dis- 
turbances other than those associated with menstruation. Accumulated 
observations leave no doubt that, in the largest number of cases of 
encysted haematocele, the blood is situated within the peritoneal sac : 
but there is abundant evidence to show that this is not invariably so, 
and that the same influences are at work in both forms. Further, Mr. 
Lawson Tait and others have shown that an extravasation of blood into 
the pelvic cellular tissue may eventually burst its restricted boundaries 
and be poured into the peritoneal cavity. It seems, therefore, unwarrant- 
able to separate the two forms of pelvic blood swelling, and to give 
them separate appellations. Both have their position deeply situated in 
the pelvis ; both arise from the rupture of, or escape of blood from vessels 
supplying the organs in the pelvis ; and in both, if the extravasation be 
suiflciently sparing and slow, the blood becomes encysted. Moreover the 
symptoms and physical signs are often so much alike as to be indistin- 
guishable. The family resemblance in the menstrual group is further 
borne out by the tendency of the tumour in both kinds to appear about 
the time of a catamenial period. If it be urged that the ovaries, 
the Fallopian tubes, and the uterus are the organs principally engaged 
in the menstrual act, and that any escape of blood from these in- 
ternally is most likely to flow into the cavity of the peritoneum, 
it may be pointed out that during menstruation, and especially at its 
commencement, the whole generative system becomes more vascular; 
the circulation in the broad ligaments is increased; the haemorrhoidal 
vessels become distended; all the pelvic organs, indeed, receive an 
increased supply of blood, and the abdomen itself becomes fuller. Rouget 
and others have described an intricate and tortuous plexus of vessels 



528 SYSTEM OF GYNECOLOGY 

lying just beneath the ovary in the folds of the broad ligaments, which 
during menstruation and other analogous conditions becomes so distended 
as to form a sort of erectile organ. This is termed the bulb of the ovary. 
Anatomical conditions favourable to the escape of blood in certain per- 
turbed states exist, therefore, in all the pelvic tissues ; but more especially 
when the catamenia occur. Looking at these anatomical conditions, it 
may be more obvious how haemorrhage takes place into the retro-uterine 
cul-de-sac of peritoneum; yet there is ample evidence that blood is 
occasionally extravasated into the cellular tissue in such quantities as to 
form a considerable tumour. Evidence from the post-mortem room is 
not sufficient to furnish data as to the relative frequency of the two 
forms, for the reasons that in the fatal cases the extravasation is more 
frequently intraperitoneal, and that death rarely takes place from the 
extraperitoneal form. Nevertheless there is other evidence forthcoming 
to prove the occurrence of the last-named form. Bernutz himself admits 
its existence, but declines to include it in the form "hsematocele." The 
opinion that hsematocele may be extra- as well as intraperitoneal was 
shared by MM. Hugier, Nonat, Eobert, Becqueril, Verneuil, and Prost. 
Nonat, after a careful study of this affection in La Pitie and elsewhere, 
states in his work on Diseases of the Uterus that he believes the extra- 
peritoneal form to be more frequent, though less grave than the other ; 
and he believes it possible to diagnose the two varieties and prescribe 
appropriate treatment for each. The late Sir James Simpson published 
an account of a post-mortem examination where the blood was undoubtedly 
beneath the peritoneum behind the uterus, and by a diagram shows the 
manner in which the serous membrane was raised up so as to form the roof 
of the cyst. In another of Sir James Simpson's cases, one of the hsemor- 
rhoidal vessels had given way, and produced a blood tumour in the 
cellular tissue in front of the rectum. Dr. Matthews Duncan convinced 
himself that the extraperitoneal is probably a common form of the 
disease, though he admits that the extravasation is intraperitoneal in 
many cases. Tuckwell collected forty-one cases where post-mortem ex- 
amination was made : of these the extravasation of blood was intra- 
peritoneal in thirty-eight; this only proves that the intraperitoneal 
form is more fatal, which we know. Byrne and Beigel believe that the 
extraperitoneal variety is much more frequent than is supposed, and the 
former states that it often gives rise to pelvic abscess or cellulitis. It 
may be that some forms of extraperitoneal hsematocele, like thrombus 
of the external parts, are especially associated with pregnancy ; as the 
pelvic vessels are then much more distended than at other times. If 
in these circumstances rupture of a vein take place into the cellular tissue 
of the broad ligament, it no doubt bears an analogy to thrombus of the 
vulva in the puerperal state ; but it is deeply situated in the pelvis, it is 
dependent on the same causes, attended by the same symptoms, and 
requires much the same treatment as the intraperitoneal form. The 
existence of extraperitoneal hsematocele is now definitely admitted by 
authors at home and abroad, and there seems no valid reason why 



PELVIC HEMATOCELE 529 

the definition of haematocele should not include this form as well 
as the other. As I have said, the majority of treatises on Diseases of 
Women adopt this definition, and it is convenient as well as practically 
useful. 

In cases of haematocele, therefore, the extravasated blood may have 
two separate localities : — I. It may be within the peritoneal cavity. II. 
It may be situated beneath and outside the cavity of the peritoneum in 
the cellular tissue of the pelvis. This is called " hsematoma " by some 
authors, and should be clearly understood to be less grave than the 
former. 

I. Concerning the intraperitoneal form of heematocele, it is necessary 
to note that there are two varieties of haemorrhage which differ, not in 
the causes or sources of the bleeding, but in its abundance and rapidity 
from whatever source it comes. Thus, if haemorrhage be abundant and 
rapid no defined tumour is formed, but the blood spreads itself over a 
large surface of the peritoneum, and the patient either speedily sinks 
from collapse or dies from the extensive peritonitis. There is no time 
or opportunity for the blood to become encysted, and hence this variety 
has been called " non-encysted haematocele or extravasation." If, on the 
other hand, blood be poured out in small quantity and sufficiently slowly, 
it commonly gravitates into the retro-uterine cul-de-sac, and there being 
surrounded by lymph barriers and adhesions which have been thrown 
out by inflammatory processes of a i^rotective character, it becomes 
encysted. The way in which blood becomes encysted to form haemato- 
cele in the retro-uterine pouch, as first described by Voisin, is as graphic 
as it is true. He says — 



When blood escapes from the ovaries, the tubes, or the uterus, it falls naturally 
behind the broad ligaments into the retro-uterine peritoneal space, limited before 
by the broad ligaments and uterus, behind by the rectum and lateral folds of the 
peritoneum, on all sides by serous membrane. Above the cul-de-sac is open and 
communicates largely with the rest of the abdominal cavity. In some rare cases 
the blood is carried in part into the vesico-uterine space, but in a very small pro- 
portion compared with the mass extravasated behind the uterus. Hardly have 
some drops of blood penetrated into the serous cavity than it inflames. This 
inflammation results in speedily establishing adhesions between all the pelvic 
organs, or rather between their peritoneal coverings. The coils of intestine are 
pushed upwards by the extravasated fluid, or rise upwards by their own lightness. 
The collection of blood encysts rapidly, thanks to the energy of the inflammation 
of the serous membrane and the formation of cellular adhesions. The sides of the 
tumour, then, are limited — before, by the broad ligaments ; behind, by the rectum 
and peritoneum; below, by the retro-uterine cul-de-sac; above, by the coils of 
intestine which, by their adhesions to the fundus uteri, the broad ligaments, the 
ovaries, the tubes, the round ligaments, and the peritoneum which covers the lateral 
parts of the pelvis, form for the cyst a sort of resisting roof. 

As will be seen on a subsequent page, some authors hold that adhe- 
sions, the result of pre-existing peritonitis, are generally present before 

2 M 



530 SYSTEM OF GYNECOLOGY 

blood extravasation takes place, and thus help to form the cyst wall of 
a retro-nterine hsematocele. 

II. In the extraperitoneal form the blood is poured out into the 
meshes of the cellular tissue which surrounds the uterus and other pelvic 
organs. It is said to be more frequent in women who have borne nu- 
merous children, and in whom the pelvic tissues are weakened and the 
areolar tissue relaxed. The tumour is much less frequently situated 
between the uterus and rectum. It may, indeed, be formed in any part 
of the pelvis where vessels ramify through the cellular tissue, and where 
the areolar tissue is lax enough to permit separation of its layers. The 
most frequent site is, laterally, between the folds of the broad ligaments. 
Here the vessels are most numerous, have the largest calibre, and, being 
surrounded by looser tissue than elsewhere, are less well supported. 
The next most frequent site is behind the uterus ; but inasmuch as the 
peritoneum is firmly attached to the posterior surface of that organ, with 
very little intervening areolar tissue, the tumour tends to run round and 
embrace the rectum, infiltrating the cellular sheath which gives it its 
mobility. Not infrequently both the lateral and posterior aspects of the 
uterus are invaded, the cellular tissue in both localities being more or 
less continuous. If the extravasated blood be considerable and the 
tumour large, the peritoneum will be separated from the structures upon 
which it normally lies, and either pushed aside, or raised upwards 
towards the cavity of the abdomen, as in the cases figured by Sir James 
Simpson and others : or the folds of the broad ligaments may be sepa- 
rated, and their upper borders elevated. The position, shape, and di- 
mensions of the swelling vary with the situation of the vascular rupture 
and the amount of blood effused. 

The blood swellings in the pelvic cellular tissue — or hsematomas — 
as a rule are not so large as those found in the cavity of the peritoneum. 
There is more resistance to the escape of blood, or a sort of natural 
h^emostasis, due to the density of the tissues permeated ; and, although 
a certain quantity of lax cellular tissue surrounds the various pelvic 
organs, it is divided by layers of pelvic fascia and the attachments of 
the peritoneum. Occasionally, however, the pressure exerted is such 
that the peritoneal layer is raised quite above the pelvis ; or the layer 
gives way, and secondary rupture takes place into the peritoneal cavity. 
There is reason to believe that small extravasations of blood take place 
much more frequently than was at one time supposed, both into and 
outside the peritoneum about the time of the catamenial periods. If 
the quantity of blood be sparing there may be no very well-defined 
swelling, and the symptoms being obscure the diagnosis is difficult. The 
results of physiological experiments, as well as observation in cases of 
laparotomy, prove that small quantities of blood effused into the cavity 
of the peritoneum speedily disappear when the serous membrane is 
healthy. The case is quite otherwise when the peritoneum has been 
altered by inflammation, for its power of absorption is then impaired or 
destroyed. After the occurrence of obscure symptoms of blood effusion, 



PELVIC ILEMATOCELE 531 

repeated, it may be, more than once, the formation of a distinct tumour 
may indicate that it is but the further development of mischief which 
may have been suspected but not verified. The evidence of tlie post- 
mortem room also points to the fact that haemorrhages both intra- and 
extraperitoneal may be progressive. 

Sources of Haemorrhage. — The sources which have been described 
are somewhat numerous ; and more extended observation has multiplied 
them. Voisin described only three causes ; namely, cougestion and haemor- 
rhage from the vesicles of de Graaf during a menstrual period ; reflux of 
blood from the uterus into the tubes and from thence into the peritoneum, 
and haemorrhage originating in the Fallopian tube itself. Bernutz speaks 
of five sources, and classes the varieties in accordance with the cause, 
thus — i. Haematocele symptomatic of rupture of utero-tubal varices ; 
ii. Haematocele symptomatic of bloody exhalation from the pelvic peri- 
toneum ; iii. Haematocele symptomatic of rupture of the ovary or 
Fallopian tube; iv. Haematocele symptomatic of difficult menstrual 
excretion ; v. Haematocele symptomatic of excessive secretion from the 
genital organs — menorrhagic haematocele. 

More recent researches have tended to the better definition of the 
sources of haemorrhage, while at the same time a larger number of sources 
is recognised. The evidence concerning some of the former supposed 
sources of haemorrhage is now regarded as indistinct and inconclusive, 
while the frequency of others is sustained by accumulated observation 
and testimony. 

i. The most frequent source of large extravasations of blood into 
the pelvis is undoubtedly the various forms of extra-uterine gestation, be 
they tubal, ovarian, or other variety. Vigues and Gal lard believed the 
rapture of a tubal pregnancy to be the cause of all cases of intra- 
peritoneal haematocele. Mr. Lawson Tait regards ectopic gestation as 
almost the exclusive cause, and likely to be always fatal unless operated 
upon. It is to be noted, however, that he draws a broad distinction, in 
respect of danger, between effusions of blood into and outside the peri- 
toneum, whether due to extra-uterine gestation or not ; but he has no 
doubt that a collection of blood from this cause, originally in the cellular 
tissue, may break its bounds and burst into the peritoneum in a secondary 
manner. Fritsch, in his Kraiiklieiten der Frauen, makes haematocele and 
the bursting of an extra-uterine pregnancy synonj^mous. In a recent 
System of Gynoicology, edited by Baldy, it is stated, in accordance with the 
teaching of Lawson Tait, that in nearly all cases ectopic gestation is the 
cause of pelvic haematocele of whatever kind. It is admitted that there 
may be exceptions, but they are rare. This statement goes too far. It 
does not accord with my own experience, and to accept it would be to 
ignore the recorded observations and opinions of some of the best authori- 
ties on the subject. Even when a tubal pregnancy has been present, it 
may have been but the indirect cause of haematocele; for the blood ex- 
travasation has occasionally come, not from rupture of the ectopic sac, 
but from a dilated vein in the broad ligament. Effusions of blood aris- 



532 SYSTEM OF GYNECOLOGY 

ing from the rupture of an extra-uterine pregnancy would, of course, be 
altogether excluded from the definition of hsematocele by authors like 
Bernutz and Voisin, who restrict the term to cases occurring as the result 
of some accident in menstruation. The symptoms are so exactly parallel 
to blood extravasations arising from other causes, and sometimes so 
absolutely indistinguishable from them, that clinically it is impossible 
to separate them. The hsematocele may be clearly discernible, but the 
cause wrapped in obscurity. The blood effused in the several forms of 
ectopic gestation is sometimes so large and sudden as to merit the 
appellation given by Bernutz as '■ dramatic," or by Dr. Eobert Barnes as 
" cataclysmic '' ; and such cases correspond to those described by Yoisin 
as "non-encysted hsematocele or extravasation." Occasionally this rupt- 
ure of an extra-uterine pregnancy takes place in successive stages, and 
by repeated attacks following exactly the course of such extravasations 
of blood from other causes ; if so the cases are most obscure, both as 
to diagnosis and causation. Mr. Bland Sutton, in explaining the way 
in which sudden and large extravasations take place in these instances 
contends that in some at least of the tubular foetations an apoplexy 
occurs in the membranes surrounding the embryo. Thus an ovum the 
size of a walnut is suddenly enlarged to the bulk of an orange, and the 
tube being unequal to the distension, gives way and rupture occurs, 
either into the peritoneum or into the broad ligament. Mr. Knowsley 
Thornton has reported an instance where the rupture of an extra-uterine 
sac, not larger than a hazel nut, gave rise to fatal haemorrhage. 

ii. Apart from pregnancy, the rupture of a vessel in some of the 
structures of the ovary is a not infrequent cause of pelvic hsematocele. 
This does not mean haemorrhage in connection with large ovarian 
tumours, when bleeding commonly takes place into the interior of cysts 
rather than outside the mass : ovarian cysts are occasionally filled with 
coagulated blood, which has been poured into their interior from the 
rupture of a vessel in the walls of the cyst ; and death has been known 
to result from intracystic haemorrhage of this kind. Nor should it in- 
clude the escape of blood from the stump of an ovarian cyst treated 
intraperitoneally, noticed by Sir Spencer Wells ; this is but an accident 
of the ovarian operation. In normal conditions it has been fully proved 
that at or about periods which correspond in the woman with the 
appearance of the catamenia, one or more Graafian vesicles, near the 
surface of the ovary, mature, become distended with blood, and at last 
rupture to discharge their contents into the infundibulum of the 
Fallopian tube. Ordinarily this physiological process is so perfectly 
performed that no blood escapes into " the ]oeritoneum from the encir- 
cling fimbriae, and little disturbance is produced. When, however, any 
antecedent morbid change has so altered the structure of the ovary as 
to induce undue hyperaemia, or to increase the size of its blood-vessels, 
or again to produce such adhesions of the fimbria as to interfere with 
the complete grasping of the ovary during the act of ovulation, then 
blood may be effused in more considerable quantity. Congestion, chronic 



PELVIC HEMATOCELE 533 

inflammation, and hypertrophy of the ovary, by enlarging the calibre of 
the blood-vessels, induce a tendency to unusual hsemorrhage at the 
period of ovulation; and the same may be said of other morbid condi- 
tions of the ovary. Yoisin arrives at the conclusion that there is usually 
some pre-existing disease of the ovary which disposes to laceration of the 
blood-vessels and consequent extravasation ; and he adduces several 
examples of haematocele produced in this way. It is by no means un- 
common in the post-mortem room to find small collections of blood in 
the substance of the ovary, especially when it is beginning to undergo 
degeneration, cj^stic or otherwise. Small cysts filled with coagulated 
blood are often found, and at times the distension has been so great as 
to produce rupture and extravasation into the peritoneal cavity. This 
catastrophe is the more likely to occur if the effects of accident or violence 
be superadded to the existing morbid condition. M. Gallard suggests 
that, in some cases, hsematocele is due to the presence of an ovule, im- 
pregnated or not, which has missed the oviducts, and with its surround- 
ing blood has dropped into the peritoneum, 

iii. The Fallopian tube, the mucous membrane of which contributes 
to the menstrual flux, would seem occasionally, when unusual excitement 
or congestion exists, to be capable of pouring out so large a quantity of 
blood as to produce hsematocele. This cause of haematocele was first 
indicated by Fenerly. It is believed, also, that if blood has been retained 
in the uterine cavity by occlusion of the os, or by displacement — such as 
extreme retroflexion of the womb — it may be driven by uterine contrac- 
tion along the oviducts into the peritoneal cavity ; or burst the tube 
and so form haematocele. Dr. Emmet thinks the regurgitative theory 
elaborated by Bernutz worth a passing notice only, and Dr. Meadows 
did not think the accident possible in the ordinary state of the tubes ; to 
make it possible they must be abnormally dilated, and the contents thus 
forced towards the fimbriae. Matthews Duncan, however, held that blood 
might be driven along the Fallopian tubes and into the peritoneal cavity 
when there was no obstruction or occlusion at the os uteri, or abnormal 
dilatation of the tubes. He pointed out that dilatation of the tubes 
occurs periodically to permit the passage of ova, as well as when patho- 
logical conditions have led to a more permanent state of dilatation and 
patency. Under these circumstances, even when the os uteri is sufiiciently 
pervious, the mechanical arrangements of the viscera and the aerostatic 
mechanism of the abdominal walls will drive fluid along the tubes, and 
so favour the production of haematocele. Trousseau held the opinion 
that a blood exhalation from the mucous membrane of the tube near 
the fimbriated extremity might account for cases of hsematocele where the 
source was the tube ; and Barnes adds a group of problematical cases 
where haematocele was attributed to blood driven along the tubes during 
abortion, on account of some hindrance to its flow by the natural passages. 

Operations during life, as well as post-mortem observation, afford 
strong evidence that haematocele may be produced by the escape of 
blood from the tubes under certain conditions altogether apart from 



534 SYSTEM OF GYNECOLOGY 

tubal pregnancy. Imlach, in several cases of laparotomy for hsematocele, 
found both tubes distended with thick black blood similar to that present 
in the abdomen. Dr. Barlow has reported a case where the tube was 
distended with clot protruding from the outer extremity — the inner 
being occluded ; and Scanzoni has described a case in which a tube was 
distended to the size of a finger and held two ounces of blood ; sixteen 
ounces had escaped into the peritoneal cavity : there was no pregnancy. 
Dr. Cullingworth has reported a case where rupture of a varicose vein 
inside the Fallopian tube produced heematocele. The haemorrhage, taking 
place from the abdominal end of a Fallopian tube, is regarded as likely 
in most instances to be progressive in its character, rather than sudden 
and abundant ; and in this way to alter the neighbouring peritoneum by 
the intercurrent inflammation it produces. Thus it is inferred that 
minor forms of haematocele may arise, accompanied with only obscure 
pelvic discomfort, and giving little evidence of tumour until accumulation 
has occurred as the result of attacks frequently repeated ; then the altered 
peritoneum, in its turn, may add accretions to the mass, by exhaling blood 
from its altered surface, as in primary hsemorrhagic pachy-peritonitis. 
These are probably some of the cases in which adhesions are said to be 
present before the formation of distinct hsematocele, as indicated by 
Schroeder and by Hart and Barbour, and in which an antecedent roof 
is partly formed over Douglas' pouch. 

Guerin advances the view that blood may regurgitate through the 
tubes, as the result of membranous dysmenorrhoea, and be effused into 
the peritoneal cavity. The mucous membrane of the uterus, he says, 
swells up so as to fill the whole cavity : this being exfoliated towards 
the end of the period may absolutely plug the os uteri ; and uterine con- 
tractions, to expel it, drive blood through the Fallopian tubes into the 
abdominal cavity. Pozzi thinks this explanation quite natural. 

iv. Eupture of vessels in the bulb of the ovary or pampiniform 
plexus, lying between the folds of the broad ligament, is enumerated 
among the causes of hsematocele by Puech, Voisin, Scanzoni, Bandl, and 
others. In certain patients the veins here, especially in the pampiniform 
plexus as well as in the lower extremities round the vulva and anus, are 
apt to become varicose. The varicose condition of the ovarian venous 
plexus is well delineated by Winckel : he states that this varicose con- 
dition is frequently met with in the post-mortem room, although Scanzoni 
believes it to be a rare one. In the varicose condition, which may be found 
in pregnant and non-pregnant women, the coats of the veins are thinned 
and weakened, and are prone to give way under increased pressure from 
muscular efforts, violence, or indeed from the hypereemia induced at the 
catamenial periods. Winckel has also shown that phleboliths in the vari- 
cose veins may ulcerate through their walls and so favour haemorrhage. 

As the veins are enclosed in the areolar tissue, it seems likely that in 
some cases an extraperitoneal haematocele would be produced by such 
rupture ; but M. Voisin states that in all cases of this kind which have 
been recorded, laceration took place into the peritoneal cavity, and the 



PELVIC HEMATOCELE 535 

loss of blood was so rapid and profuse that no time was allowed for it 
to become encysted, and immediate death, was the result. 

V. Tardieu and Bernutz, with others, have described instances of 
intraperitoneal haematocele, where the source of bleeding was the altered 
surface of the peritoneum itself. Virchow explained this as a process 
similar to that which occurs in " pachymeningitis pseudo-membrosa," in 
which a like exudation has been noticed. Band! gives it the name of 
" pelvi-peritonitis hsemorrhagica." Dolbeau, who gives his adhesion to 
this theory, asserts that an immense number of cases of retro-uterine 
haematocele are produced by pelvic peritonitis of the hsemorrhagic form, 
and this explains the less serious nature of some instances as compared 
with those having a tubal, ovarian, or varicose source ; as the bleeding is 
then more oozing in character. 

Hart and Barbour state that it is disputed whether inflammation 
encysting and limiting the haemorrhage is antecedent or consequent on it ; 
and think the former view has more evidence in its favour, although 
some cases support the latter: they give one example, recorded by 
Lauchlan Aitkin, where the usual physical signs of retro-uterine haemato- 
cele were observed during life — namely, a retro-uterine tumour bulging 
into the posterior fornix and displacing the uterus markedly forwards 
— on post-mortem examination the clotted blood was found without 
adhesions. Schroeder believed that peritonitis always precedes the 
occurrence of haematocele. Veit says, if the abdominal cavity be healthy 
no encapsulation of blood occurs ; but, if adhesions be present, blood 
from whatever source clots on them, and fresh adhesions are formed 
which create a new cyst wall. Schroeder was a capable and sagacious 
observer, and it seems probable from available evidence that encysted 
haematocele may be formed either with or without pre-existing pelvic 
adhesions. In the former case, if blood be extravasated below the 
adhesions, and a restraining roof be thus previously formed for the 
haematocele, the tumour as felt per vaginam will be firm and prominent 
from the first. When there have been no pre-existing pelvic adhesions, 
a longer time may elapse before peritonitis lighted up by the extravasa- 
tions has formed limitations for the blood cyst, and so the haematocele 
may not be recognisable so early. The pre-existence of peritonitis, by 
impairing the functions of the ovaries and tubes, may indirectly dispose 
to pelvic haemorrhage, and the adhesions produced by peritonitis may 
furnish it ; but there are certainly many cases of pelvic haematocele, even 
of the encysted form, in which there has been no previous history of 
inflammation. 

Intraperitoneal haemorrhage has been known to occur as the result of 
forcible attempts to replace a distorted or displaced uterus which has 
been bound down by pelvic adhesions ; and by other forms of violent 
procedure. 

vi. Another source of intrapelvic haemorrhage has been described 
which differs from the preceding, inasmuch as there is no antecedent 
peritonitis; but blood oozes from the genital surfaces — internal and 



536 SYSTEM OF GYNECOLOGY 

external — and especially from the surface of the peritoneum. To this 
pathological condition Bernutz gives the name of " metrorrhagic hsema- 
tocele." It may be associated with the '"' metrorrhagic diathesis " or with 
haemophilia; and it has been particularly noticed during the progress of 
eruptive fevers ; Trousseau therefore called it " cachectic." Dr. John 
Phillips has recorded a case in association with rheumatism which he 
regarded as '^cachectic." The formation of hsematocele internally is 
preceded and accompanied by excessive catamenial discharge from the 
uterus and vagina ; and it is presumed that a simultaneous haemorrhage 
takes place from the surface of the inner genital canals and of the peri- 
toneum. A diminution of fibrin in the blood has been supposed to favour 
this exudation. 

Bernutz has collected many examples under this head, which he has 
classed in groups according to certain characteristics or differences. Be- 
longing to this order are not only haematoceles characterised by some 
cachexia, but also those associated with anaemia and chlorosis, in which 
cases the blood is impoverished and thus more easily escapes from the 
vessels. Although it is well established, by reasons previously stated, 
that hsematocele unassociated with pregnancy takes place most frequently 
at or about the time of the catamenial period, yet the affection occurs in 
some instances where the catamenia are absent, and where presumably 
the ' function of evolution is suspended. During pregnancy, and after 
delivery and abortion, extravasation of blood, both into and outside 
the peritoneum, may give rise to a pelvic blood swelling, having all the 
characters commonly observed in typical hsematocele. Examples of this 
kind have been recorded by West, Yoisin, and Bernutz. 

Pathological Anatomy. — Before describing the morbid appearances 
in cases of hsematocele proper, it may be well to indicate what takes place 
in those instances where, the cause being the same, hsemorrhage takes 
place so rapidly and in such profuseness that no time is permitted for 
the blood to become encysted. The reports of post-mortem examinations 
in such instances are proportionally much more numerous than in those 
of encysted hsematocele, inasmuch as the former much more frequently 
end fatally. No better description is to be found in any author than that 
originally given by Yoisin. He says " in the non-encysted form it is 
generally found after death that the skin of the body is devoid of colour, 
and the belly tumid, more particularly in the region of the hypogastrium. 
Black fluid blood may escape in considerable quantity when the abdomen 
is laid open. The intestines are distended with gas, and pushed up 
above the mass of blood contained in the pelvic cavity. The abdominal 
organs are often covered with clots, the intestines stained of a bluish 
colour, and in one recorded instance the mesentery was infiltrated with 
blood. The amount of blood — fluid and coagulated — contained in the 
pelvis and abdomen has repeatedly been found to be as much as four 
pounds." Of twenty cases quoted by Voisin the source of hsemorrhage 
was traced in sixteen to some distinct lesion : in six, the hsemorrhage 
came from the ovary ; in four, from rupture of an ovarian varix ; in two, 



PELVIC HEMATOCELE 537 

from the cavity of the uterus ; and in four, from the Fallopian tube. In 
the remaining four no distinct lesion could be found, and it was supposed 
that the haemorrhage arose as an exhalation of blood from the surface 
of the peritoneum. In these statistics no mention is made of the rupture 
of a Fallopian tube, or of any other form of extra-uterine gestation, for 
blood extravasations in association with pregnancy were excluded by 
Yoisin. In instances where such extravasation is dependent on the 
bursting of a foetal cyst, and if, as is frequently the case, death take place 
speedily from shock and the quantity of blood effused, some trace of the 
embryo may be found in the mass of coagulated blood. It is to be 
noted that ordinarily in these cases rupture takes place early — about the 
second or third month ; although I have seen such a rupture as late as in 
the fourth month. In the very early cases it may be difficult to find 
traces of the embryo ; but it may be less difficult to find villi of the 
chorion, either swimming in the effused blood, or attached to the lacera- 
tion from Avhich the blood has escaped. The presence of either leaves 
no doubt as to the cause of the catastrophe. It must, nevertheless, be 
recollected that first there may be a limited haemorrhage, which will form 
an encj^sted haematocele ; and that this may be followed by a second and 
more abundant haemorrhage of the non-encysted variety which carries off 
the patient. The post-mortem signs in such a case would be much more 
complex than when only one haemorrhage had occurred. 

As the subjects of encysted haematocele commonly recover, the number 
of autopsies has been comparatively few. In those recorded no great 
tumefaction of the abdomen was seen. On opening the abdomen the 
general surface of the peritoneum was found healthy, except that ad- 
hesions were occasionally remarked between the intestines. If any of 
the adhesions forming the boundaries of the cyst had been torn, or other- 
wise broken down, so as to allow the cyst contents to escape (and these 
are the cases most likely to terminate fatally), the usual products of in- 
flammation were found — more or less redness and vascularity, lymphy 
exudations, purulent serum with albuminous flakes. One or both 
Fallopian tubes have been found distended with blood. Sometimes there 
have been indications of preceding salpingitis, and lacerations have been 
detected in the Avails of the tubes, in one of the ovaries, or in the vessels 
of the broad ligament. Imlach states that in fifteen cases of laparotomy 
for haematocele he found both tubes distended with black, thick blood. 
In none of these instances could there have been a question of tubal 
pregnancy, or the distension would probably have been limited to one 
side. 

To take a typical example of the morbid appearances in intraperi- 
toneal haematocele from Yoisin : " On a level with the brim of the pelvis 
the viscera were seen to be united together, forming the roof of the cyst. 
The bladder was elevated above the pubes ; the uterus close behind it, 
somewhat increased in size, and rotated upon its axis, in a position 
different to the usual one. Behind, adhesions united the posterior and 
superior aspect of the uterus to the rectum, a portion of the sigmoid 



538 SYSTEM OF GYNECOLOGY 

flexure of the colon, and several coils of small intestine, the two broad 
ligaments, and the posterior half of the circumference of the brim of the 
pelvis. A roof was thus formed over the posterior half of the pelvic 
excavation. On laying open the cyst the thickness of the walls was 
found to vary with the amount of fibrinous exudation at the point of 
incision. The cyst cavity was divided into a number of compartments 
by cellular bands, but communication existed between the various loculi. 
All the pelvic organs were more or less fixed, the ovaries displaced, and 
completely lost among the inflammatory products. In an opening which 
had been effected previous to the decease of the patient, traces of ulcera- 
tion were found, and the fistula between the aperture and the cyst was 
sinuous and irregular." 

The contents of the cyst vary with the date at which the blood extrav- 
asation took place, and with other circumstances in the history of the case. 
If time has elapsed after the blood has become encysted, it is usual for 
the contents of the cavity to consist of clots more or less altered in colour 
and arrangement, sometimes of a variable quantity of black fluid, grayish 
at certain points, sometimes like a mixture of soot and water. At times 
the fluid has a tarry, syrupy consistence ; and if suppuration has occurred, 
there is an admixture of pus. Such products have been observed also 
when the cyst has been evacuated during life. Under the microscope the 
contents have been found composed of blood globules completely bereft 
of colour, and so altered in shape as to be scarcely recognisable ; besides 
these are fat globules, amorphous particles of hsematoidine, various 
crystals, and other materials resulting from the transformations of the 
effused blood. In most cases of encysted hsematocele the displacement 
and confusion of parts is so great, in consequence of the effused blood and 
subsequent inflammation, that the determination of the source of haemor- 
rhage is most difficult. Erom various data, however, the blood seems to 
have come from rupture of a previously diseased ovary in the largest 
number of instances. 

In certain cases post-mortem examination has revealed indications of 
attempts at spontaneous cure. There have been solidification and changes 
of colour in the blood-clot, absorption of fluid, and contraction of the sac, 
which is filled with a growth of connective tissue coloured with blood 
pigments. These results have been observed when a subsequent attack 
of haemorrhage has supervened on a previous one, or when the patient 
has succumbed to some intercurrent disease. 

Causes. — Among the remoter causes must first be mentioned that of 
age. Haematocele occurs during the period of greatest sexual vigour in 
women. Dr. Tuckwell found that the decade between twenty and thirty 
years of age was the period of its most frequent occurrence. According 
to Schroeder the largest number of cases occur between twenty-five and 
thirty-five. Out of forty-three cases twenty-seven occurred between 
those ages. Concerning the frequency relative to other diseases of 
women there is a wide diversity of opinion. Thus Hugenberger reported 
only 2 in 3801 cases ; and Scanzoni, in twenty-eight years of practice, 



PELVIC HEMATOCELE 



539 



had only seen eight cases : Olshausen, on the other hand, places it as high 
in frequency as 4 per cent of all female diseases, and Dr. Barnes also 
believes it has a large relative frequency. Bandl holds a position between 
the two extremes of opinion. Marriage seems to have little influence 
in its production. Apart from ectopic gestation some deviation from 
normal conditions in the function of menstruation has been noted by all 
observers to precede the advent of hsematocele. Thus it has been generally 
remarked that the largest number of patients suffer habitually from pro- 
fuse menstruation — the colour of the discharge being bright and clots 
frequent. Yoisin remarked that the greater number of hsematoceles 
occur at the end of the catamenial period, which somewhat militates 
against his view that the habitually profuse menstrual flow observed in 
this class of patients is due to a plethoric condition of the system, and 
against his inference that a recurring over-distension of the blood-vessels 
in plethoric patients favours the formation of hsematocele. Bandl, again, 
regards the frequency of hsematocele in connection with the monthly 
periods as due to the high blood pressure in the ovarian arteries at those 
times which, having been weakened by morbid changes, give way. 

Against these theories it may be stated that the high pressure of the 
arterial circulation is said to be greatest at the beginning of the function, 
not at the end; and, again, menstrual haematocele undoubtedly occurs 
occasionally in feeble and anaemic patients whose menstruation has been 
suspended, it may be for months ; and who are the subjects of amenorrhoea. 
In these cases the rupture of an internal blood-vessel does not necessarily 
take place from any physical obstruction to the catamenial flow by the 
natural passages, but from constitutional conditions which have impaired 
the quality of the blood and weakened the integrity of its containing 
walls. In persons of more robust health, in whom blood extravasation 
takes place towards the end of the period, the explanation is probably to be 
found in some fault of ovulation, more particularly in the ovarian cases. 
There are many reasons and observations which point to the fact that the 
extrusion of an ovule and the accompanying rupture of an ovisac take 
place towards the end of the menstrual flow, not at the beginning. Hence 
the greater liability to attacks of hsematocele at that time. 

The morbid changes in the blood observed during the progress of the 
exanthemata and other fevers, in purpura and in allied cachectic con- 
ditions, frequently lead to attacks of haemorrhage from the mucous canals ; 
the same conditions have been remarked as predisposing causes of haema- 
tocele. Further, it has been observed that although in the menstrual 
history of most women attacked with hsematocele, the recurrence of the 
periods may have been regular, the discharge was habitually too profuse 
and prolonged. Whether abundant or scanty, however, it was nearly 
always attended with pain, due either to obstruction or to a congested 
condition of the parts concerned. The cases were few in which the pain 
was due to obstruction ; and in these there was either contraction of the 
cervix or a displaced fundus. In the rest the dysmenorrhoeal suffering was 
but the expression of a faulty performance of function in the generative 



540 SYSTEM OF GYNECOLOGY 

organs, associated with over-distension of its blood-vessels. Among other 
indirect causes are a weak and varicose condition of the veins in the 
pelvis, vulva, and lower extremities. Women who have varicose veins of 
the lower limbs and are liable to haemorrhoids, to venous swellings in the 
vulva, and to a weighty, spongy condition of the uterus, habitually 
menstruate too profusely and painfully, and these are the patients most 
prone to hgematocele. 

The immediate causes enumerated are sudden suppression of the cata- 
menial flow, over-fatigue, violent straining at stool, cold (especially cold 
foot baths during menstruation), intense mental emotion, premature 
exertion after abortion, and violence producing injury during menstrua- 
tion. In a considerable number of cases the immediate cause was traced 
to coitus, which had taken place either during the catamenial period or 
shortly after its termination; and the pain began during the sexual 
act. 

Symptoms and Progress. — There are three modes of invasion, and the 
symptoms vary for each mode. In the first and most severe mode, 
corresponding to the non-encysted variety of Voisin, the onset of the 
symptoms is overwhelming. The patient is abruptly seized with severe 
abdominal pain and rigor ; these symptoms are succeeded by utter prostra- 
tion of strength, cold extremities, pallor of countenance, which is anxious 
and pinched, and subnormal temperature ; the pulse is rapid and weak, and 
the general surface of the body becomes deadly pale. -The attack may 
come on when the patient is apparently in good health; and it has been 
suggested that the suddenness and intensity of the attack may possibly 
lead to a suspicion of poisoning. In many cases, certainly, the symptoms 
bear a very close resemblance to those produced by perforation of the 
stomach or other abdominal viscus, with extravasation of their contents 
into the peritoneum ; but in addition there is marked anaemia produced 
by sudden and profuse loss of blood, and the attack is often either co- 
incident with a menstrual period or is preceded by symptoms of pregnancy. 
The belly becomes tender and hard as well as dull on percussion, but 
there may be no local tumour observable, as there has been no time for 
its definition by the formation of adhesions. In these cases Bernutz 
observes, " we must be upon our guard against too hastily concluding 
that there is no sanguineous extravasation because there is no perceptible 
hypogastric or retro-uterine tumour, or because the tumour is slow in 
developing itself." If there is no abatement in the severe symptoms, 
hiccough and vomiting occur, the temperature sinks further, and the 
surface of the skin becomes colder and more blanched. Syncope or com- 
plete collapse speedily follows, with a small, almost imperceptible pulse, 
and death generally ensues within twelve hours. Such sudden and cata- 
clysmal symptoms are commonly observed with the rupture of a tubular 
or other form of extra-uterine foetation. Although extremely perilous 
such cases are not necessarily fatal. Instances have occurred in which 
the patient has rallied from what was apparently a hopeless condition, 
and the ovum has died or gone on developing to a later period of 



PELVIC HyEMATOCELE 



541 



pregnancy, eitlier in its original site, or in some other locality where it 
had become lodged after being extruded at the time of rupture. 

The second mode of invasion corresponds with ordinary forms of en- 
cysted hsematocele, extra- or intraperitoneal. Here the symptoms are to 
some extent the same in character as in the non-encysted form, but those 
common to both are less in severity. The gravity of the attack varies 
in accordance with the suddenness and the amount of blood extravasa- 
tion, and the general condition of the patient. The severity of the 
attack will be modified by the seat of the effused blood — being more 
acute and ^threatening when the blood is poured into the peritoneal 
cavity, less so when the effusion is into the cellular tissue — for the double 
reason, that less disturbance is provoked Avhen blood is extravasated 
beneath the peritoneum than on its free surface; and that effusion is 
likely to be slower and more gradual into the meshes of the cellular 
tissue. In both cases the first symptoms indicate pain, exhaustion, and 
more or less pronounced collapse, due to the escape of blood internally, 
and they are followed by symptoms of pelvic peritonitis. It has been 
noticed by several writers that the amount of collapse bears no sort of 
relation to the amount of blood effused, and is always greater in cases of 
intraperitoneal hsematocele because of the sensitive surface. Emmet says 
he detected by accident, in one instance, an accumulation of blood going on 
in the peritoneal cavity without the patient suffering any discomfort ; and 
Dr. Playfair has observed an instance where a considerable quantity of 
blood was found in the peritoneum, though there had been no antecedent 
symptoms of such a nature as to indicate its presence. Here, probably, 
the serous membrane had been altered by the previous inflammatory 
changes surrounding an ovarian tumour ; but such cases are rare and 
exceptional. Commonly the illness is preceded by some notable derange- 
ment in the catamenial function, and dates from a menstrual period, 
which has perhaps been attended with more than usual pain, the dis- 
charge being inordinately profuse and prolonged beyond the normal 
limits. Then immediately after some such effort as straining, coitus, or 
the like, comes a rigor, with sudden and intense pain in the pelvis often 
compared to the throes of parturition, and increased by pressure or 
movement. If the blood effused be considerable in quantity, and 
particularly if it be thrown into the peritoneum, there is fainting almost, 
amounting to syncope, and this is conjoined with signs of local peri- 
tonitis. In several instances it has been noticed that the patient, having; 
been exposed to cold or undue exertion during meustruation or im- 
mediately after it, has awoke in the night with a sense of exhaustion and 
faintness, and has begged to be supplied with food. This preliminary 
exhaustion has speedily been succeeded by abdominal pain and other- 
characteristic symptoms. The pain may be dull and continuous, or 
paroxysmal, with recurring exacerbation ; and a weight about the anus is 
often complained of, with frequent ineffectual attempts to evacuate the 
bowels. There is often tenesmus, and quantities of mucus may be passed 
— possibly mixed with blood — indicating irritation of the intestinal mu- 



542 SYSTEM OF GYNECOLOGY 

cous membrane. Painful micturition is not infrequent, and partial or 
complete retention of urine may lead to complications in diagnosis and 
mask the real ailment. The patient prefers to lie upon her back, with 
the thighs flexed on the abdomen, as usually observed in cases of peri- 
tonitis ; and there is often considerable distension of the intestines by 
flatus. Great nervous disturbance is often a prominent feature in these 
attacks of illness. Coma and insensibility are rarely present, but rather 
marked distress and restlessness, very inimical to the quietude so 
necessary for the patient, and severe neuralgic pains, not only in the 
pelvis but also in the lower limbs and elsewhere. The sort of paralysis 
of the intestines of some patients is believed by Poncet to be brought 
about by the joint effect of pressure in the pelvis and the general nervous 
exhaustion. Supervening on the stage of exhaustion or collapse, acute 
febrile symptoms speedily develop themselves, with rapid pulse, increase 
of temperature, and loaded urine. To these symptoms Voisin adds — 
as a very characteristic sign of the nature of the affection — a rapidly 
produced and marked pallor of the skin, which assumes a dull white- 
ness not unlike that which accompanies the cancerous cachexia. 

The tliird mode of invasion is that in which the symptoms are devel- 
oped very gradually and in succession ; the case assuming a chronic form. 
Such instances undoubtedly exist, and are beset with difficulty, as they 
are apt to be confounded with other affections. As previously remarked, 
there is no doubt that small extravasations of blood take place in the 
deeper parts of the pelvis without forming a distinct tumour, or being 
attended by very definite symptoms. These attacks may be repeated 
more than once, at uncertain intervals, until one occurs of a character 
so acute or intense as to leave no doubt of its nature, and connecting 
itself clearly with the former attacks of less distinctness. In this way 
there may be many varieties both in reference to the severity of the 
attack and the time of its recurrence ; and the same patient may be the 
subject of the slighter or graver forms of the malady. These repeated 
attacks may be associated with the various forms of ectopic gestation, 
with the " hsemorrhagic peritonitis " before named, or with intermitting 
haemorrhages from the Fallopian tubes. 

Metrorrhagia is one of the commonest concomitant symptoms of 
pelvic haematocele in all its varieties. So large and continuous in some 
cases is the loss of blood by the natural passages, that this symptom 
mainly engrosses the attention of the medical practitioner, to the exclu- 
sion of the changes taking place in the deeper parts of the pelvis. 
Metrorrhagia is, however, not always present. 

If the extravasation be large, and yet not too large to be localised, a 
tumour is soon to be discovered through the abdominal walls, above the 
pubes, in the direction of the iliac fossa on either side, or projecting 
downwards in the interior of the pelvis. Dr. West says that he has 
detected the swelling within forty-eight hours after the first symptoms, 
and in many cases it may be detected earlier, especially if it be circum- 
scribed by previous pelvic adhesions ; although a certain time must 



PELVIC HEMATOCELE 543 

elapse before the blood becomes so consolidated as to be accurately 
defined. At the first onset of the attack no distinct local tumour may 
be detected, though the abdomen may be distended by meteorism. 
When detected it is commonly only somewhat tender to x)ressure ; but 
occasionally careful examination is rendered impossible for a time by the 
extreme sensitiveness. The tumour is best examined as the patient lies 
upon her back ; as then external and internal palpation can be combined, 
and the most accurate estimate formed of the size, consistence, and 
relations of the mass. Exploration by the vagina and rectum should 
rarely be omitted, as in this way the position of the swelling between 
the vagina and bowel is at once ascertained. 

In the physical examination of the tumour it is important to recollect 
that it presents a succession of changes in its density in accordance with 
its duration. As soon as it can be defined it presents the characters of 
dulness on percussion, immobility, or very partial mobility, and more or 
less of irregularity in outline. Soon after its formation it is elastic and 
indistinctly fluctuating; later it is irregular, and of unequal density — 
the firmness of its borders closely resembling the results of pelvic 
cellulitis. If considerable in size, and retro-uterine, it is found on 
vaginal examination to occupy the posterior half or more of the pelvis, 
elevating and pushing forward the cervix uteri above the pubes, stretch- 
ing and pushing down the posterior wall of the vagina, and compressing 
the rectum behind it into the concavity of the sacrum. In rarer 
instances, wdiere the tumour is more or less in front of the uterus, the 
cervix uteri is thrown backw^ards. Chassaignac has reported a case in 
which the sanguineous effusion was entirely between the bladder and 
uterus, thus forcing the entire uterus backwards. In all cases the tumour 
seems fused into and more or less united to the uterus. Nevertheless 
the uterus may occasionally be moved in some degree independently, both 
with the finger and the uterine soimd. Where the uterus is pushed up- 
ward and forward by a blood mass in the posterior part of the pelvis, it 
may be traced in outline by external and internal palpation ; and the 
sound verifies its position, proving that the displacement is not due to 
retroflexion. Matthews Duncan noticed that the length of the uterine 
cavity was much increased whenever the hsematocele was large, and that 
it decreased with its contraction. Frequently the blood tumour has been 
observed of such dimensions as almost to fill the true pelvis, and to 
distend and push down the back wall of the vagina so far that it 
almost reached the vulva. Where the swelling projects very low in the 
pelvis it has been supposed that it must necessarily be due to extravasa- 
tion into the cellular tissue, because the peritoneal cavity has a higher 
level ; but when it is recollected that the peritoneum is often prolonged 
far down the posterior wall of the vagina, and that the lower boundary 
of the cul-de-sac almost reaches the floor of the pelvis, this deduction is 
seen to be of uncertain value. The tumour sometimes seems much lower 
in the pelvis than it really is, owing to a large amount of oedema of the 
recto-vaginal septum below the true level of the haematocele. This is 



544 SYSTEM OF GYNECOLOGY 

occasionally so considerable as to form a distinct rounded swelling 
projecting towards the vagina, and it is found also in some cases of 
cellulitis. The bulging of the tumour downwards is not universal even 
when blood occupies the retro-uterine cul-de-sac, or is in the lowest 
meshes of the cellular tissue : the retro-uterine pouch may have been 
unusually shallow, or it may have been partially obliterated by previous 
pelvic adhesions, as indicated by Schroeder. This author gives illustra- 
tions, showing large collections of blood in the pelvis, the lower margin 
of which is on a level with or a little below the upper part of the sym- 
physis pubis ; in one of these diagrams the true pelvis is represented 
as nearly fall of blood. In these cases the finger would have to be 
carried up to the fornix vaginae, or even higher, to reach the lower 
border of the tumour. When the position of the tumour is other than 
retro-uterine it will displace the pelvic organs in accordance with its 
dimensions and relative position. On more than one occasion, being 
formed in front of it, it has been stated to have produced complete retro- 
version of the uterus. Sir James Simpson, Dr. Graily Hewitt, and others, 
give illustrations in outline of the extraperitoneal form or limmatoma of 
some authors. In one of Graily Hewitt's cases the hsematic tumour 
rose as high as the crest of the ilium on the right side, and dipped half 
way down the pelvic canal inferiorly. In the second, the extravasated 
blood is represented as surrounding the bladder, uterus, and rectum in 
every direction — as in Hart and Barbour's diagram — and the tumour so 
formed reached as high as the umbilicus above, and to within a short 
distance of the perineum below. These, however, are extreme cases, and 
it must be noted that the illustrations are diagrams, and do not profess 
to be pathological drawings. More frequently in the extraperitoneal 
form, or hsematoma, the swelling will only be felt by internal examina- 
tion ; it will be distinctly lateral in position, occupying one of the broad 
ligaments, fixing the uterus much in the same way as in pelvic cellulitis, 
and, in many cases, if seen in the later stages, quite indistinguishable 
from it. Occasionally the quantity of blood effused is so small that, not- 
withstanding the presence of characteristic general symptoms, no well- 
defined tumour can be detected. Drs. West and Matthews Duncan, 
who had noticed the absence of distinct tumour in some of these cases, 
inferred that the extravasation was too extensive to become circumscribed ; 
but there are certainly instances where the general symptoms are very 
marked and characteristic, and yet the amount of effusion has been so 
slight as to produce but little local tumefaction. 

In some rare cases more than one hsematic tumour has been observed 
at the same time ; one situated in the iliac region, for example — felt 
by external examination — the other lying deeply in the pelvis, and 
reached only by vaginal exploration. It is, of course, possible that 
these apparently separate tumours may have been poles of one long 
mass. 

Some authors have enumerated among the symptoms, during the 
progress of haematocele, an undue pulsation of the arteries in the vagina 



PELVIC HJEMATOCELE 545 

and cervix uteri; but this is an uncertain symptom, and in a case 
described by Dr. Madge, in the Obstetrical Transactions, it was notably 
absent, as was also the pain in defsecation so commonly observed. 

Among the occasional symptoms are blood in the urine ; severe pains 
in the lumbar and sacral regions and down the limbs ; oedema of the 
lower extremities and vulva; and, more rarely still, phlebitis in the 
crural veins produced either by pressure or blood poisoning. A still 
more exceptional symptom has been observed by some writers in connec- 
tion with extraperitoneal hsematocele, namely, an ecchymosed colour of 
the vagina ; and in two cases ecchymosis of the abdominal wall. 

The progress varies very much with the age of the patient, her con- 
dition of health at the time of the seizure, and the character of the 
attack. Sometimes the attack sets in with great violence and the pro- 
gress is rapid. In the majority of cases the entire extravasation of blood 
takes place in a very short time from the commencement of the attack, 
although at first it may not be possible to define a tumour. In a few 
hours, however, or at least in a few days, the swelling is detected, and it 
may attain the size of a child's head, or of a gravid uterus at six months. 
When once formed it does not necessarily increase in size except in the 
cases of progressive haematocele. The suddenness of its appearance, and 
the rapidity of its full increase in size, are important points to be 
noted in distinguishing it from the results of pelvic cellulitis and other 
morbid conditions. 

Instances present themselves in which the symptoms are less acute. 
Blood seems to be poured out in small and progressive quantities at 
certain intervals, creeping on as it were — the increase of swelling, in the 
menstrual cases more particularly, corresponding with the monthly 
periods. After the tumour has attained its full development — whether 
it has been formed rapidly or by progressive steps — the natural tendency, 
if not interfered with, is gradually to decrease in size. The tumour, at 
first soft and semi-fluctuating, becomes harder to the touch and of unequal 
density, and the sense of fluctuation gradually disappears. These altera- 
tions arise from the changes which take place in the extravasated blood; 
the serum becomes absorbed, while the coagulum remains and undergoes 
the changes observed elsewhere in blood-clots, growing harder and denser. 
The remains of the clot with the induration incident to the attendant 
pelvic peritonitis is often found months or years after the attack. It has 
been noticed by many authors that when once the tumour has reached 
its full development, and is no longer increased by the occurrence of the 
catamenial period, the menstrual flow seems to exert a beneficial effect. 
With each recurring normal period there is a marked decrease in size, 
the improvement taking place as it were by leaps instead of by gradual 
and continuous absorption. Voisin, Prof. Dolbeau, and Poncet dwell 
particularly on this feature. When menstruation is present at the onset 
of the attack the function may be suddenly checked, and only return after 
an uncertain interval. The rule is, however, that instead of being 
arrested, it becomes so profuse as to be a marked feature of the case ; 

2n 



546 SYSTEM OF GYNECOLOGY 

and when restrained within moderate limits, often persists for weeks as a 
further drain on the strength of the patient. 

When the case is not interfered with by injudicions surgical pro- 
cedure, and suitable palliative measures are adopted, the natural tendency 
in all instances, except those which have been called cataclysmic, is for 
the more formidable symptoms to subside gradually. The effects of 
shock are recovered from, the pain and febrile signs decrease, and after 
a time the patient experiences only great weakness, with a train of 
symptoms more chronic in character, due to the presence of the mass in 
the pelvis, and more or less marked in accordance with its bulk and 
situation. There may be a sense of weight in the pelvis, bearing down, 
some difficulty in micturition and defaecation, and pain and discomfort in 
attempting to walk or assume the sitting posture. If one side of the 
pelvis be occupied by the tumour the nerves and vessels of the lower 
limb on that side may be compressed or irritated, and pain in movement 
may be experienced on the affected side only. 

As a rule, therefore, recovery takes place slowly, by resolution; the 
blood and surrounding adhesions are gradually absorbed, and the damage 
done is ultimately repaired. This holds good even in the larger forms of 
hsematocele, if let alone; supposing always that the blood mass is safely 
surrounded by limiting adhesions. In twenty-five cases noted by Voisin 
fifteen terminated by absorption. The average duration is found to be 
about four months. Braun, in twenty-four cases, noticed absorption 
to be complete in six months, and Bandl's figures point in the same 
direction ; but one of his cases took six and another eight months to 
recover. 

As in cases of cellulitis the recovery is sometimes a very slow one, 
and subject to many interruptions. The function of the pelvic organs 
may remain impaired for months or years after the attack, with indica- 
tions of thickening around them, or perhaps of salpingitis or other affec- 
tion of the tubes. 

In a small proportion of patients suffering from hsematocele, recovery 
does not take place by resolution, as in the more favourable cases, but 
suppuration occurs in the blood-cyst. The contents may then be 
evacuated by one of the pelvic canals. There is a divergence of opinion 
whether suppuration always precedes the evacuation of the cyst. The 
failure to detect pus in the discharges has been thought to indicate that 
simple ulceration of the containing walls may sometimes account for the 
evacuation, without any preceding suppuration. When suppuration does 
take place there is usually a reaccession of febrile symptoms, often pre- 
ceded by rigors and attended by rise of temperature and profuse perspira- 
tion. If spontaneous evacuation occur, the patient passes a quantity 
of fluid and semi-solid material, which in appearance has been compared 
to currant jelly, and in odour to decaying flowers. In twenty-seven in- 
stances, cited by Voisin, six emptied themselves by the rectum, three by 
the vagina, and four burst into the cavity of the peritoneum. This last 
mode of termination (said ^by Pozzi to be rare, whether produced by 



PELVIC HEMATOCELE 547 

suppuration or not) is by far the most perilous, inasmuch, as it is uni- 
formly followed by general peritonitis and death. The danger of rupt- 
ure into the peritoneal cavity is always increased by the occurrence of 
suppuration ; hence the necessity of early artificial opening when once 
the fact of suppuration is beyond doubt. Bandl states that the most 
frequent exit in spontaneous evacuation is by the rectum, and this is 
not devoid of danger as it may set up exhausting diarrhoea. The open- 
ing not being in the most dependent part of the cyst, faecal matter may 
find entrance, foul gases be formed, and septic materials generated which 
infect the whole system. These results are accentuated if more than 
one opening occur, and these may be into the rectum and vagina at the 
same time. When no general septic infection occurs the patient may 
be worn out by diarrhoea, persistent high temperature, impaired nutri- 
tion, and exhausting sweats. 

Matthews Duncan dwelt on the importance of recognising the exist- 
ence of fluid in the lowest part of the sac, in hsematocele of some stand- 
ing, as indicative of the presence of pus. He modified his opinion later, 
and taught that the mere presence of fluctuation, unless preceded by 
general and local signs of suppuration, is not sufficiently trustworthy, 
and is apt to lead to an erroneous conclusion. The secondary inflam- 
mation and suppuration of a hsematocele, particularly if the indications 
of suppuration are so indistinct that artificial evacuation cannot be 
resorted to, may protract the recovery of a patient indefinitely. The 
formation of purulent matter at times takes place so insidiously that the 
first distinct proof of its existence is the discharge of pus and broken 
down coagula or coffee-ground-like material by the rectum. M'Clintock 
gives an example of a patient dying from a persistence of these exhaust- 
ing discharges, and Madge a case in which a woman died from the com- 
bined effect of exhausting discharges and phlegmasia dolens. 

Further, it appears that intercurrent peritonitis may complicate the 
progress of hsematocele, and this apart from the rupture of the cyst. 
By this is meant that, after the first inflammatory action has subsided 
which formed the boundaries of the original blood-cyst, peritonitis more 
or less severe in character supervenes at times from slight causes during 
the progress of the case. These attacks may be severe or slight — gen- 
eral or partial in character : in all cases they entail further peril ; and 
at no time during the persistence of the hsematocele is there an immu- 
nity from their reappearance. Yoisin observed this mode of fatal 
termination in one case as late as three months, and another at the end 
of four months after the date of the original attack. 

Diagnosis. — The points of distinction between hsematocele and other 
morbid conditions found in the female pelvis require very careful study. 
In an ordinary case there may be no great difficulty ; but it should be 
borne in mind that mere physical examination, without careful investi- 
gation into the history of the invasion, and a review of all the subjective 
symptoms, is not sufficient. 

i. A suspension of the catamenia for one or more periods when they 



548 SYSTEM OF GYNECOLOGY 

have been heretofore regular, and symptomatic changes in the mammae 
with other signs of pregnancy previous to an attack, may point to the 
rupture of a tubular or other form of extra-uterine pregnancy. Such 
cases are generally attended by very grave symptoms, as ordinarily the 
extravasation of blood into the peritoneum is so large that there is no 
opportunity for its limitation by adhesions, and the patient speedily dies 
from shock and peritonitis. And the cause of the catastrophe in these 
cases is not always easily ascertained. Such eminent authorities as 
Eobert and Hugier both acknowledge that they have mistaken a blood 
extravasation produced by rupture of an extra-uterine foetation, and 
occupying a considerable space in the pelvis and abdomen, for pelvic 
hsematocele arising from other causes. Death does not necessarily occur 
in all these instances. The effused blood, if not too extensive, may, 
together with the ovum, become surrounded by adhesions as in other 
forms of haematocele ; and either be absorbed, or, if the ovum retain its 
vitality, continue its development in its new nidus. Possibly before 
the sudden invasion of illness a swelling may have been detected in 
process of extension on the lateral margin of the uterus. This with 
signs of early pregnancy clearly point to ectopic gestation. 

ii. The affections which of all others bear the closest resemblance to 
pelvic heematocele in its chronic stages, and are most likely to be mis- 
taken for it, are the various forms of pelvic cellulitis, pelvic peritonitis, 
and the after stage of pelvic abscess. The formation of a correct opinion 
is often most difficult ; and, at some stages, without the aid of a suc- 
cinct history which is not always forthcoming, well-nigh impossible. 
Even with a clear history the differential diagnosis is frequently by no 
means easy. It may aid discrimination to remember that attacks of 
pelvic cellulitis are more frequent than haematocele. Pelvic inflam- 
mation and abscess are more frequently consecutive to abortion and 
delivery ; or, when not so, have generally some relation to a previously 
existing inflammatory condition in the uterus or ovaries : they are not 
generally accompanied with menorrhagia, they are not attended by 
rapidly produced pallor of the skin and anaemia, and the swelling, if 
watched throughout its course, is more likely to begin in the lateral and 
deeper parts of the pelvis, is comparatively slow in formation, and is 
hard from the first. If sux^puration occur, it becomes soft and fluctuat- 
ing later. Haematocele, again, is more commonly connected with some 
accident of menstruation, and reaches its greatest intensity suddenly ; 
the tumefaction is more frequently behind the uterus ; it is soft in its 
early stages, and grows harder as time passes on, beginning to fluctuate 
again if the cyst inflames and suppurates. 

A further point of difference is that, in haematocele, if the swelling be 
at all considerable, it is more or less rounded in form, with hard inflam- 
matory margins ; and it displaces the uterus in accordance with the 
position of the blood swelling, but commonly forwards in the intraperi- 
toneal form, with the neck carried high above the pubes. In pelvic 
inflammation, properly so called, the fibrinous deposit is infiltrated 



PELVIC HEMATOCELE 549 

through, the pelvic tissues affected, fixing the uterus more or less in its 
normal position so that it cannot be elevated or depressed. When 
cellulitis is extensive it fixes all the viscera in the pelvis to the osseous 
boundaries, as if plaster of Paris had been poured into the pelvis and 
had hardened there. Again, the constitutional symptoms follow an 
inverse order in the two affections — febrile disturbance distinctly pre- 
cedes the formation of tumour in the inflammatory affection, it follows 
it in haematocele. 

These distinctions refer more particularly to the early or acute stages 
of the affection. When a case is seen for the first time in the chronic 
stage — that is, a considerable time after the supervention of the original 
attack — it may be more diificult to determine its true nature. The 
presence of tumour or thickening in the pelvis may, of course, be due 
either to previous cellulitis or peritonitis ; or it may primarily have its 
origin in an extravasation of blood upon which inflammatory action has 
supervened. It is only by a careful study of the history of the attack 
that the difficulty can be solved. It may be equally difficult to deter- 
mine, when a patient is not seen until suppuration has occurred, whether 
abscess be the result of primary phlegmonous inflammation or be the 
secondary product of a suppurating hsematocele. Fortunately the treat- 
ment in the two cases is practically the same, and the patient suffers 
no disadvantage from a failure to decide concerning these perplexing 
difficulties. 

iii. Voisin and others have stated that the diagnosis between hsema- 
tocele and inflammation of the ovary with its products is often very 
dif6.cult. The degree of difficulty will vary, of course, with the stages 
at which the patient comes under observation ; but ordinarily there will 
be no great difficulty in discriminating between the two. The points of 
difference are the limitation of pain and swelling, in the earlier stages 
of ovaritis, to the locality of one or other ovary, and a certain amount 
of febrile disturbance in the incipient stage. 

When a considerable swelling has formed as a consequence of a long 
and intense attack of ovaritis, which has extended to surrounding parts 
and become complicated with pelvic cellalitis and peritonitis, it should 
be noted that there has been no sudden invasion or rapid formation of 
a tumour, as in hasmatocele ; no sudden anaemia ; perhaps no coincident 
menorrhagia ; and the symptoms gradually increase in severity from the 
commencement, while in h-eematocele the most severe symptoms appear 
from the first, and as time passes, undergo gradual amelioration. 

iv. The various forms of uterine and ovarian tumour of limited size, 
beyond the remote resemblance on physical examination, would seem to 
have very little in common with haematocele. Yet Asch reports a case 
where a supposed haematocele was punctured through the vagina, and 
was found to be an ovarian cyst which was afterwards successfully re- 
moved. Tumours are to be distinguished by the absence of urgent symp- 
toms from the commencement, by their slower growth, circumscribed 
form, and generally by their mobility. An ovarian tumour is commonly 



55° SYSTEM OF GYNECOLOGY 

lateral in position, and, if it sinks into the nterine cul-de-sac, it is rarely, 
as M^Clintock has pointed out, so low as blood gravitating there from 
the peritoneal cavity. A more perplexing situation arises if an ovarian 
cyst, prolapsed behind the uterus, inflames and suppurates, or possibly 
ruptures there. Inflammation of the cyst, which does not proceed to 
suppuration, may throw out lymph deposits which mask the rounded 
form of the original tumour, and thus the softer centre with harder 
margins may simulate the physical characters of hsematocele. The 
diagnosis might be still more obscured by oedema of the recto-vaginal 
septum, which, when inflammatory action goes on in the posterior cul- 
de-sac, may at any time thrust forward the posterior wall of the vagina, 
and lead to a sense of fluctuation there. The only way out of these 
difficulties is to study the history carefully and to watch the progress of 
the case. In the lapse of time, as inflammatory action subsides, it may 
be observed that the serous and lymphy effusions are absorbed, while the 
central tumour remains. If this is fluctuating and unattended with con- 
stitutional signs of suppuration, it is pretty certain to be ovarian. If 
suppuration take place in an ovarian cyst so placed it is usually, but not 
always, attended by characteristic constitutional signs. In all doubtful 
cases, where it is of importance to ascertain the true nature of the fluct- 
uating swelling, recourse may be had to an exploring needle or aspirator 
as recommended by Sir James Simpson and Professor Braun. 

Sudden and profuse haemorrhage into the cavity of a large ovarian 
cyst may be attended by some of the general symptoms of hsematocele. 
There would be the indications of internal haemorrhage in both cases, 
with the production of rapid anaemia. Fortunately such cases are not 
frequent, as the distension of ovarian cysts by other contents exerts a 
restraining influence against large blood extravasations into them. Still, 
as before mentioned, death has resulted from this cause and the diagnosis 
may be difficult. In the ovarian haemorrhage there would probably be 
the history of a previously existing tumour ; and the uniformity and 
smoothness of its surface and the absence of swelling in the recto-uterine 
pouch, should lead to a correct conclusion. 

Fibrous tumours of the uterus, as a rule, bear no sort of resem- 
blance to haematocele, either in their history or physical characters ; 
but seeing that such experts as Malgaine and Stoltz have mistaken 
them for haematocele, it may be well to say a word or two on 
the differences. Malgaine and Stoltz both attempted to remove 
tumours, supposed to be fibroids of the uterus, which proved to be retro- 
uterine haematoceles, and both cases ended fatally. Beyond the fact 
that the two affections are commonly attended with haemorrhage there 
are not many points of similarity. Fibroids of the uterus are distin- 
guished by their history of slow, painless growth, by their density, by 
their position, and by their attachments to the uterus. There is no 
sudden production of anaemia. Yet uterine fibroids, particularly if situated 
behind the uterus, may give rise to sudden attacks of pain arising from 
inflammation ; and the difficulty of determining whether a pelvic tumour 



PELVIC HjEMATOCELE 551 

IS solid or has fluid contents should not be underrated. A distended 
pelvic cyst may feel so hard and dense as to simulate solid growth ; a 
iibroid, on the other hand, may be so soft, particularly if previously in- 
flamed, that it may seem to have fluid contents. The only way of mak- 
ing an accurate differential diagnosis in doubtful cases of this nature is 
by the use of the aspirator or exploring needle. 

Of malignant growths in the pelvis probably only encephaloid tumours, 
which are rare, run any chance of being mistaken for hsematocele. As 
they may be attended with the general aspect and pallor so constantly 
observed in hsematocele, there is a possibility of error ; but the gradual 
development of the malignant growth, and the supervention of anaemia 
and waxiness in the skin, with other indications of the cancerous ca- 
chexia, in the later rather than in the earlier stages of the affection, 
would be suthcient distinctions. Dr. Playfair has recorded an instance 
where hsematocele was produced by the bleeding of malignant growths 
in the peritoneum, and became one of its secondary complications, in- 
creasing the difficulty of diagnosis. 

V. Eetroflexion and retroversion of the gravid uterus, ^oarticularly 
those forms in which the symptoms appear suddenly from violent efforts 
or accident, are said to have been occasionally mistaken for hsematocele. 
The cervix uteri in both cases may be so displaced upwards and forwards 
as almost to be out of reach of the finger ; and when there is a suspicion 
of pregnancy the sound cannot in prudence be used to aid diagnosis. To 
arrive at a correct conclusion it will probably be enough to note that, 
in the case of a displaced gravid uterus, there has been a suspension' 
of menstruation, characteristic changes in the breasts,' and other symp- 
toms of pregnancy; the retro-uterine tumour is circumscribed and 
smooth, without hard adhesions on its borders ; the cervix uteri has a 
partial mobility, and can be traced backward to the swelling behind, 
while there is an absence of all tumour above the pubes. In some 
instances the fundus may be raised up with the finger in the posterior 
vaginal fornix or in the rectum. On the other hand, whenever hsematocele 
is of considerable size, it can probably be felt above the pubes, and the 
whole uterus can be traced lying in front of it. The value of signs 
connected with the mobility of the womb, empty or gravid, would neces- 
sarily be vitiated where old adhesions bind it backwards, and perhaps 
make the outline of the fundus irregular from the deposits about it. In 
the unimpregnated uterus the use of the sound would show the direction 
of the uterine cavity and the position of the fundus. In the gravid 
organ the history, more particularly the early s^miptoms of pregnancy, 
would in most instances be sufficient to indicate the nature of the case. 

vi. Fsecal accumulations in the rectum are to be distinguished from 
hsematocele by noting that ordinarily they can be indented by the finger 
pressing through the vaginal wall. If harder, a digital exploration of 
the rectum will reveal their true nature. 

vii. The difficulty in distinguishing between the intraperitoneal 
form of hsematocele and the extraperitoneal (hsematoma of authors) is 



552 SYSTEM OF GYNECOLOGY 

admitted. Frankenliauser and Bandl suggest, as a solution, the placing 
of the patient in the knee-chest position before the blood becomes cap- 
sulated by adhesions ; then, if in the peritoneum, it will flow out of 
Douglas' space, and return again when the patient assumes the dorsal 
position. Posture would not affect the haematoma. This is a test 
which must have a very limited application, and is scarcely to be recom- 
mended ; for besides the difficulty of attempting it with a patient in 
a state of collapse, it would tend to prevent the desired encapsulation 
of the effused blood, and extend the peritonitis. The points to be noted 
are the more usual lateral position in haematoma — displacing the ute- 
rus to the opposite side; the bulging round the uterus, not confined 
to the pouch behind; the less degree of shock and collapse than in 
intraperitoneal haematocele, and the delay of the inflammation. The 
mass is unlikely to be so large as to displace the uterus upwards and 
forwards as it does when the haemorrhage is intraperitoneal. 

viii. Serous effusion into the pelvic cellular tissue, associated with 
some of the low forms of pelvic inflammation, may be a further source 
of confusion in diagnosis. Crede of Leipzig tapped a tumour of 
uncertain origin and got serum first, then blood-stained serum, and 
finally blood. If the swelling fluctuate, only the history and use of an 
aspirator can clear up its nature. Sir James Simpson and Sir John 
Williams have both noted this serous effusion in the pelvic cellular 
tissue, and it was pointed out as a source of fallacy by myself in the 
article " Haematocele " in Eeynolds' System of Medicine. 

The prognosis, depends much upon the extent of the haemorrhage 
and the gravity of the attendant symptoms in particular cases. In the 
majority of instances, if the right treatment be adopted, and the medical 
man can be persuaded to abstain from hurtful surgical interference, 
the prognosis is favourable. Dr. F. Weber of Berlin, a careful writer 
on this subject, states that of twenty- three cases observed by him none 
were fatal, — a result he ascribes to his method of treatment, which is 
the application of an ice bladder, perchloride of iron internally, and avoid- 
ance of puncture. Poncet, again, is emphatic in holding that recovery 
is the rule if no surgical interference be practised. These authors would 
probably, however, except cases where blood extravasation is so large as 
not to become encysted, and also ruptures of ectopic pregnancies. In 
all cases there must be a degree of uncertainty; for when vascular 
rupture has taken place in the pelvis, it is impossible to foresee to what 
amount the haemorrhage may extend ; or, when once apparently checked, 
whether there shall be a renewal to a fatal amount. There are, besides, 
the dangers arising from subsequent peritonitis, which may overwhelm a 
feeble patient ; and from the liability to low forms of chronic peritonitis, 
creeping on in patients not seemingly in immediate peril, with a tendency 
to aggravation at the catamenial periods. To these may be added the 
drain upon the strength when a cyst suppurates and discharges through 
the bowel or vagina. The incessant diarrhoea and hectic so set up not 
unf requently have exhausted the vitality of a patient who has survived a 



PELVIC HEMATOCELE 



553 



primary attack ; and, if fhe contents of the intestine get into the sac, 
they may favour the absorption of septic materials and general blood 
poisoning. Again a suppiirating cyst may burst into the peritoneum, 
and speedily be followed by a fatal result. Lastly, if a patient escape 
the effects of the original attack, and also the risks of suppuration, she 
is apt to be long in a condition of incomplete recovery with the pelvic 
organs more or less fixed, the tubes and ovaries possibly occluded, and a 
certain amount of hardness from deposit surrounding the uterus. The 
chronic persistence of this deposit, while it lasts, not only may inter- 
fere with the normal function of menstruation, but be a permanent 
cause of sterility. It must, nevertheless, be repeated that the general 
tendency is towards recovery, if the effects of the primary attack are 
surmounted ; also that the absorption of the products left Ijehind may 
be complete. 

Treatment may be considered first as preventive or prophylactic, and 
therapeutic or actual when once an attack has occurred. The therapeutic 
treatment may again be divided into treatment of the primary attack 
and the treatment of its consequences. 

Tlie propliylactic treatment consists in guarding those who may be 
most liable to hsematocele from the exciting causes of its development. 
The women of some families seem more prone to it than others ; and 
therefore, if one member has suffered in this way, her sisters should 
take precautions, more especially if liable to certain symptoms which 
seem associated with its production. Thus women who suffer from 
dysmenorrhoea, particularly in the congestive form ; or in whom, from 
any obstruction, the escape of the menstrual flow is difficult, should be 
warned to observe rest and the recumbent posture during the catame- 
nial period. In the intervals they should be submitted, if practicable, 
to treatment of the painful and difficult menstruation. Women who 
have varicose veins of the lower extremities, of the vulva, or of the 
rectum, in the form of haemorrhoids, and the like, and who menstruate 
therewith painfully and with abnormal profuseness, should likewise keep 
the recumbent position during the periods, and avoid all the causes which 
have been known to provoke hsematocele. Particularly they should 
avoid travelling, over-exertion or exposure to cold during menstruation ; 
coitus should be interdicted altogether near the catamenial period, and 
iX other times practised moderately and without violence. 

When an attack has occurred, the medical man will in the first place 
have to treat the patient in the stage of shock, and in doing so will 
have to consider the pathological cause. The object should be to palliate 
the symptoms of collapse, and to restore the depressed vitality of the 
patient without doing anything which would tend to increase the extrav- 
asation of blood. jSTon-encysted extravasations, whether arising from 
the rupture of an extra-uterine foetation or from some other cause, are 
as a rule so speedily and certainly fatal that all palliative treatment is 
likely to be useless, and the question of laparotomy pushes itself inevi- 
tably to the front. This will be discussed later. Since, however, there 



554 SYSTEM OF GYNECOLOGY 

are at first no means of accurately ascertaining the extent of the blood 
effusion — either at the moment or prospectively — nor the probability 
of its becoming encysted, the rational plan of treatment consists in sus- 
taining the strength of the patient, relieving the pain, and adopting 
such measures as are likely to stay the flow of blood, to promote its 
coagulation, and to limit it in such fashion that it may become encysted 
by subsequent adhesions. These general indications apply both to the 
extra- and intraperitoneal forms, but are the more urgent in the latter. 

The first thing, therefore, is to ensure at once absolute repose in the 
recumbent posture, to impress upon the patient the importance of 
restraining restlessness and impatient movements and of avoiding all 
mental emotion or other disturbance of the general circulation. A full 
dose of opium or morphia will have the double effect of soothing the 
pain and restlessness, and of lessening the depressing effects of loss of 
blood ; sinapisms may be applied to the upper extremities by way of 
diverting the circulation in that direction. In cases of extreme collapse 
the hypodermic injection of ether may be employed, and a solution of 
common salt (a teaspoonful to a pint of boiled water) may be injected 
into the veins or into the rectum, as may be more practicable. Some 
French authors have recommended that, in the early stage, venesection 
should be practised once or twice, to produce a derivative effect on the pel- 
vic vessels, and to lessen the pressure in the systemic circulation generally, 
and on the internal bleeding points more particularly. Aran recommended 
twenty or thirty leeches over the abdomen on the first day, fifteen to 
twenty on the second, and twelve to fifteen on the third day, if the 
constitutional condition of the patient would bear it and the feebleness 
were not too great, He testified to the favourable results of such treat- 
ment, and to the shorter duration of the cases. He supported the 
strength during depletion by nutritious diet, and followed up the 
leeching by blisters and other forms of counter-irritation to the abdomen. 
Neither general nor local depletion has found favour in Great Britain. 

The local application which has been found most effective is an 
ice-bag over the hypogastrium ; or, if ice cannot be procured, cold com- 
presses over the seat of pain. Hot fomentations and poultices are to 
be sedulously avoided lest, in the attempt to relieve pain by their use, 
they should promote the further flow of blood internally. The diet 
should be simple, unstimulating, only enough to prevent exhaustion ; and 
all drinks should be cool or cold, so that the circulation be not suddenly 
stirred. For the same reason if brandy or other stimulant be given — 
and this may be urgently needed — it should be given only in small quan- 
tities frequently repeated. Various astringents and haemostatics may 
be administered if thought desirable — sulphuric acid, tannic or gallic 
acid, acetate of lead, perchloride of iron, ergot (by hypodermic injection), 
digitalis, etc. Whichsoever the agent chosen it may be well to combine 
it with opium. When the symptoms of shock have subsided, and the 
period of reaction sets in, it becomes necessary to prescribe for the febrile 
symptoms, and to combat the signs of local peritonitis. Frequent vaginal 



PELVIC HEMATOCELE 555 

or even external examination should be avoided, especialty with the 
sound or other instruments, as disturbing to the patient and likely to 
interfere with the integrity of the adhesions forming round the extrav- 
asated blood. For the same reasons the use of purgatives should be 
avoided. The urine should be drawn off with a catheter, and every 
movement or disturbance of the patient obviated as much as may be. 
The main points to be attained are absolute repose and the relief of pain 
by opium or morphia, which may be administered by the mouth, rectum, 
or hypodermically as seems most expedient. If thought desirable the 
ice-bag can be continued, as it may relieve pain and lessen the intensity 
of the peritonitis. If the signs of local peritonitis are very severe, and 
the patient's strength will bear it, the application of a few leeches to the 
hypogastrium or anus may now be an advantage ; but they cannot be 
applied to the cervix uteri without more disturbance than is desirable. 
Leeching, with hot vaginal douches, as recommended by Bernutz and 
Goupil, are less objectionable at a later stage. These Bernutz advises 
at the approach of a catamenial period both to x^romote the flow, and to 
facilitate the absorption of the pelvic tumour. 

In regard to the surgical treatment of the primary attack there has 
been great fluctuation of opinion ; but the matter seems now to be settled 
absolutely in favour of non-interference in the extraperitoneal form, and 
also in a large proportion of intraperitoneal cases. The exceptions to 
this rule, more particularly in the last-named class, are those instances 
where the quantity of blood effused, whether it result from the rupture 
of an abnormal pregnancy, or from some other cause, is obviously so large 
or continuous that there is little chance of its becoming successfully 
encysted ; and the patient is evidently doomed if left to the natural 
powers of recovery. In such instances, probably the only chance of 
saving the patient is the performance of laparotomy at once, or as soon 
as the first rally from shock will permit, and the securing of the bleed- 
ing points, with the removal of the clots. Could we be certain of the 
diagnosis in cases of rupture of tubular and other forms of extra-uterine 
gestation, there would no doubt be a consensus of opinion as to the pro- 
priety of opening the abdomen as soon as practicable after the occurrence 
of the " cataclysmic " or " dramatic " symptoms so rapidly supervening. 
For not only is there the risk of one attack of haemorrhage succeeding 
another, but tliere is the danger of the ovum becoming necrosed in the per- 
itoneal cavity, and producing septic infection; or possibly, if the patient 
recover, of the continued development of the o\nim either in its original 
abnormal seat, or in some other locality to which it has been transplanted. 
In these latter circumstances a primary operation would be but to antici- 
pate what most probably would be required later. Unfortunately accurate 
diagnosis is frequently so little assured that the question of operating 
must be determined rather by the urgency of the symptoms than by the 
pathological cause. If doubt exists it is wise to abstain from surgical 
interference, for not only have large extravasations of blood producing 
voluminous intra- and extraperitoneal tumours been entirely resolved, 



556 SYSTEM OF GYNECOLOGY 

but there is reason to believe that ova extruded into the peritoneal cavity 
may oceasionally be absorbed, and thus give no further trouble. 

The rule of non-interference by primary surgical procedure in other 
cases than those associated with abnormal pregnancy has been evolved 
from the experience of many authorities. Nelaton at first employed 
the method of puncture and evacuation in all cases indiscriminately. In 
several instances where puncture was practised the patients were attacked 
with purulent infection and died. This led to a modification of treat- 
ment, and artificial evacuation was resorted to only when the symptoms 
were urgent. Later Nelaton taught that surgical interference was only 
warrantable when such threatening symptoms were present as to cause 
apprehension of rupture of the adhesions forming the parietes of the cyst, 
and extravasation of the contents into the general peritoneal cavity. 
Thus where a hsematocele of considerable size already existed, and 
appeared to be increasing in size — being attended by constant and 
violent pain — he concluded that secondary inflammation was going on 
in the cavity, and that the cyst walls would probably give way, and fatal 
peritonitis be the result. The statistics of Voisin, published in his ex- 
cellent monograph, although not now recent, were decidedly adverse to 
artificial evacuation as a general plan of treatment, and led him to prefer 
an expectant method, unless the case were exceptional and threatening. 
Thus out of twenty cases where surgical interference was resorted to, 
fifteen recovered and five died. In contrast with this, out of twenty- 
seven cases treated by the expectant method, twenty -two recovered and 
five died. Deducting from the last class two deaths in which haematocele 
was apparently not the immediate cause of death, the mortality, when 
no operation was performed, was one in nine, but was one in four when 
an artificial opening was made. Voisin's statistics were probably too 
limited to form a trustworthy guide, and these are sources of fallacy 
which must be guarded against. Thus it does not appear whether the 
cases operated upon and chronicled by Voisin were slight or severe. 
He was a pupil and follower of ISTelaton, and therefore it is probable 
that some of Voisin's cases treated by puncture were instances of the 
worst form, and that an opening was imperatively called for by the 
severity of the symptoms. The results tabulated by West show that 
of fifty-five cases treated on the expectant plan forty-three recovered 
and twelve died, while of forty-eight cases of surgical interference forty 
recovered and eight died. Here again sources of fallacy may lower 
the value of the statistics, unless it be clearly shown whether the cases 
operated upon were of such gravity that they could not safely have been 
left to the expectant method. 

Meadows boldly advocated a more frequent recourse to puncture 
in cases where the quantity of blood effused was, comparatively 
speaking, inconsiderable in amount. He made use of Voisin's 
statistics in support of his contention. At the time there was no 
great difficulty in showing that the figures relied upon by Dr. 
Meadows were untrustworthy, because sources of fallacy were not 



PELVIC HEMATOCELE 557 

sufficiently eliminated; and both, opinion and practice in later days 
have steadily veered towards a more conservative method, even in cases 
deemed to be intraperitoneal. Following the precepts of Nelaton, such 
later writers as Thomas, G-usserow, Pozzi, and others, only recommend 
surgical interference in serious cases, each of which is to be judged by its 
individual peculiarities. Auvard goes so far as to say that nineteen out 
of twenty cases of hsematocele will end well by simply ensuring repose in 
bed. In striking contrast to this is Lawson Tait's opinion that nearly 
all cases are fatal if not operated upon. He, however, looks upon 
almost all cases of intraperitoneal haemorrhage as due to tubal pregnancy, 
and has been in the singular position of seeing none other. 

No division of opinion exists as to the right course to pursue in the 
later stages of haematocele. When indications of suppuration are once 
clearly established, artificial evacuation should be undertaken as soon 
as practicable ; not only by way of obviating the possible catastrophe of 
the suppurating cyst bursting into the peritoneal cavity, but also with 
the object of securing a drainage more favourable to the recovery of the 
patient than if the abscess be left to spontaneous rupture. It has been 
pointed out that spontaneous evacuation of haematocele is apt to take place 
through the intestine, because a larger surface of the bowel is surrounded 
by the tumour than of the vagina, uterus, or bladder. This is not nearly 
so favourable an exit as by the vagina, where drainage may be established 
without setting up the irritation which by the rectum is inevitable. 
Evacuation should therefore always be made by the vagina when pos- 
sible. There may be a certain number of cases where, notwithstanding the 
presence of general signs of suppuration, fluctuation cannot be felt by the 
vagina. In these instances exploration must be made by the rectum 
as well as by the vagina, and the question of opening be determined by 
the result. Thanks to the modern use of antiseptics, both abdominal 
sections and artificial evacuation can now be undertaken with less risk of 
septic infection than in former days. The admission of air into the sac, 
setting up putrefaction, the recurrence of secondary peritoneal inflamma- 
tion, and the renewal of haemorrhage, were common results in former 
times when incisions or puncture were practised either before or after 
suppuration. The dangers of operation, nevertheless, are multifarious 
and not lightly to be encountered. A patient under the conjoint care of 
Malgaine and Nelaton died of haemorrhage from a posterior uterine artery 
which was wounded by puncture ; and a patient operated upon by 
Hugier died of peritonitis provoked by injecting warm water to wash out 
the contents of the cyst. Recent results happily testify that operations 
on haematocele, when imperatively called for and carefully conducted, 
are somewhat less perilous than at one time they appeared to be. 
Matthews Duncan, a careful observer and a decided conservative in 
reference to operations, and Professor Braun, both testify to the truth 
of this statement. Both observed a shorter duration and more rapid 
cure after artificial evacuation in appropriate cases than they expected. 
Improvement in the result of operations is partly to be attributed to the 



558 SYSTEM OF GYNECOLOGY 

better selection of cases, partly to the nature of the operation, and 
largely to the introduction of antiseptic precautions. In the earlier 
operations puncture of the sac by a trocar was chiefly practised ; and 
this, while it allowed the admission of air, probably carrying germs of 
disease with it, relieved the tension, but did not ensure free drainage 
or the exclusion of clots. Sir James Simpson long ago recommended, 
instead of puncture, a freer opening with a tenotomy knife, and gradual 
enlargement with the fingers, so as to lessen the chance of wounding 
large vessels, and to permit more solid matters to be discharged. This 
larger opening by the knife is now generally admitted to be the best 
practice : in addition to other advantages it permits the more efficient 
antiseptic treatment of the cavity, which can then be stuffed with iodo- 
form gauze to obviate the formation, of septic products within. The 
gauze must, of course, be introduced with great gentleness, and under no 
circumstances should fluid be injected, lest the fragile adhesions forming 
the cyst boundaries towards the peritoneum be broken down. An open- 
ing by the vagina may not always prevent a spontaneous opening in 
another direction. In a case of Dr. West's, puncture by the vagina was 
followed by an opening into the bowel ; hence, if spontaneous evacua- 
tion by the rectum seem inevitable from pointing in that direction, it 
may be best to open artificially there, notwithstanding the disadvantages 
named. The question arises, nevertheless, whether, if fluctuation in any 
degree can be detected by the vagina, it may not be well to make an 
incision there, even if discharge have already appeared by the rectum ; 
as the counter opening will prevent the retention of faecal and other 
contents in the abscess cavity. 

In summary, it may be stated that as a general rule it is best to treat 
cases of hsematocele — intraperitoneal as well as extraperitoneal — by a 
palliative method, relieving the symptoms by appropriate remedies, and 
taking such precautions as are likely to ward off fresh complications. 
When the blood extravasation is extraperitoneal no need to deviate from 
this plan is likely to arise, but it should be pursued as far as possible 
irrespective both of the size and position of the heematocele ; and in a large 
proportion of cases, if perfect quiescence be enforced, the tumour, even if 
of considerable dimensions, will gradually disappear. If, however, the 
symptoms are very severe, or the tumour once formed, instead of sub- 
siding, shows a tendency to increase, with repeated recrudescence of 
urgent symptoms, it becomes a question whether, notwithstanding the 
risks, laparotomy should be performed for the double purpose of remov- 
ing the contents of the tumour and securing the bleeding points. In the 
cachectic cases there would be less hope of doing good by operation than 
in others ; each case must be judged on its own merits. Again, whenever 
in the after stages of the affection constant and severe pains, the occur- 
rence of rigors, and marked increase of temperature at nights, with other 
hectic symptoms, indicate that suppuration has taken place, then artificial 
evacuation, by the vagina if practicable, becomes imperative as soon as 
fluctuation can be detected. In some rare cases, where no distinct signs 



PELVIC HEMATOCELE 559 

of suppuration have occurred, the urgency and persistence of certain 
severe symptoms may yet call for operative interference. Thus the 
persistence of severe and chronic vomiting, which has been observed 
associated with large hsematoceles, and continued and alarming obstruc- 
tion of the bowels, as observed by Meadows and others, may call for 
some diminution in the amount of physical pressure. In such instances 
Routier, who at one time preferred laparotomy, has declared his prefer- 
ence for vaginal incision as less hazardous 5 and his position is supported 
by Zweifel, von Strauch, and other authorities. Eegnier, again, prefers 
abdominal section, but his preference should be regarded with caution, 
as he would extend abdominal section to cases treated by others on the 
expectant plan. If there be reason to suppose that haemorrhage is still 
going on within, and that the boundaries of the blood-cyst are not 
consolidated, probably the least hazardous course would be to perform 
laparotomy rather than make an incision by the vagina. This operation 
is the more to be preferred where there is a suspicion that the case is 
associated with ectopic gestation. As to the technique of this operation, 
Pozzi says that " the sac should, if possible, be fixed to the abdominal 
wall by ' marsupialisation,' emptied, plugged, and drained. But this 
theoretical manoeuvre is rarely practicable on account of the absence 
of a well-formed and resistant cyst wall ; the latter generally has no 
individuality, and is simply formed by adhesion of neighbouring parts. 
The surgeon may then be forced to content himself with antiseptic 
flushing of the cavity." It is obvious, however, that this flushing must 
be of the gentlest character, lest the temporary adhesions be broken 
down. In such a case it would be wise to plug the orifice with iodo- 
form gauze, and provide capillary drainage. 

The after treatment of hsematocele in its more chronic forms, and 
more especially in cases not operated upon, deserves careful attention. 
The indications are to prevent as far as possible the recurrence of 
haemorrhage or other active symptoms, and to promote the absorption of 
the extravasated blood with the inflammatory products surrounding it. 
It is necessary, therefore, at the catamenial periods to prescribe abso- 
lute rest in the recumbent position until recovery is completed ; in the 
intervals the amount of exertion should be carefully regulated. Violent 
efforts or straining should be avoided, as well as all excitement of the 
sexual organs. The bowels should be made to act easily, and the diet 
should be nutritious, but not over-stimulating. If there is ansemia, and 
this associated with dribbling bloody discharge from the uterus, acid 
chalybeates, such as the sulphate or perchloride of iron, combined with 
mineral acids and other tonics, may be prescribed. The iodides and 
bromides of iron have been found useful in promoting the absorption of 
deposit and thickening if they continue long after an attack ; and these 
may be aided by the local application of blisters, tincture of iodine, and 
mercurial and belladonna ointments. Sir James Simpson used vaginal 
suppositories or pessaries medicated with iodides and mercurials for this 
purpose. 



56o SYSTEM OF GYNECOLOGY 

The precautions to be adopted when spontaneous evacuation has 
taken place will depend on the locality of exit. If opening has taken 
place per vaginam, then probably all required will be strict antisepsis and 
generous diet. If perforation has been through the intestine, in addition 
to tonics and good food, opium or morphia may be required to stay the 
diarrhoea, and such precautions as are possible to ward off the tendency 
to recurring peritonitis and septicaemia. The question of counter-opening 
into the vagina may arise in such cases, particularly where the symptoms 
are grave, and there seems a likelihood of reaching the most depending 
part of the sac through the genital canal. 

As the patient, even when fairly recovered, may still have indications 
of impaired health, deranged menstruation, and possibly of deposit 
remaining in the pelvis, care and precaution will be required for a pro- 
longed and indefinite period. The avoidance of great exertion or of much 
travelling should be enjoined, and rest at the monthly periods. Change 
of air should be prescribed if it can be procured, and every advantage 
Avhich, by improving the general health, will conduce to full recovery. 

W. 0. Priestley. 



REFERENCES 

1. Amer. Syst. of Gyn. Ed. by Mann, 1887.— 2. Asch. Cent. f. Gynec. 1887. — 3. 
AuvARD. Traiteprat.de gyn. 1894:. — 4:. Baldy. Text-Book of Gyn. 1894. — 5. Bandl. 
Billroth's Handhuch, 1879. —6. Barlow. Edin. Med. Jour. 1841. — 7. Barnes. St. 
Thomas' Hosp. Reports, 1870; and Obstet. Trans, vol. xiii. etc. — 8. Bernutz. Archives 
de medecine, 1848; and Diseases of Women, by Bernutz and Goupil, Syden. Soc. ed. — 
9. BiEGEL. Arch. f. Gyn. 1811. — 10. Bourdon. Revue medicale, 1841. — 11. Braun. 
Weiner Med. Wochenschr. 1861. — 12. Breslau. Monat. f. Geburt, etc. vol. ix. — 13. 
Byrne. On Pelvic Hsemat. 1862; and Obstet. Soc. New York, 1888. — 14. Credb. 
Monatschriftf. Geburt und Kind. vol. ix. — 15. Cullingworth. Obstet. Trans. 1890. — 
16. DoLBEAu. Med. Times and Gazette, 181Z. — 17. Duncan, Matthews. Edin. Med. 
Jour. 1862 and 1865. — 18. Emmet. Principles and Pract. of Gyn. 1884. — 19. Engel- 
hard. Archiv.de7nedec.1851. — 20. Fbnerly. These inaugurate, 1855. — 21. Fbrber. 
Arch, f Heilk. 1862, No. 5.-22. Follin. Gazette des hopit. 1855.-23. Fritsch. 
Volkmann's Sa)nmhing,'No. 56. — 24. Gallard. Union medicale, 1855; Gaz. hebdom.. 
1858.-25. Goupil. Syd. Soc. Trans. — 26. Guerin. Clin. Lect. Dis. of Female Gen. 
Org. p. 439.— 21. Gusserow. A7'ch.fiir Gyn. 18G6-61. — 28. Hugier. Lecture before 
Surg. Soc, Paris, 1851.-29. Imlach. Brit. Med. Jour. 1885 and 1886.-30. Labor- 
DORiE. Gazette des hopit. 1854. — 31. Laugier. Comptes rendus, yoI.xI. — 32. M'Clin- 
tock. Diseases of Women, 1865, etc. — 33. Madden. Dub. Jour. Med. Sci. 1892. — 
34. Madge. Obstet. Trans, vol. iii. — 35. Martin. Dasextra-periton.peri-ut.hsematom. 
1881. — 36. Meadows. Obstet. Trans, \ol.x\n.— SI. Monod. Bull.de la Soc.de Chir. 
1851.-38. Nblaton. Gazette des hopit. 1851. — 39. Nonat. Traiteprat.desmal.de 
Vuterus, etc. 1874. — 40. Olshausen. Aj-chiv f. Gyn. 1870.-41. Phillips. Obstet. 
Trans. 1887. —42. Piogey. Bull, de la Soc. Anat. 1850.-43. Playfair, W. S. Obstet. 
Trans. 1884 and 1889. — 44. Poncet. " Haematocele," Diet, encycl. de med. sc. mM. 
1886; Hsematocele peri-uterine, Thes. 1877. — 45. Pozzi. Treatise on Gynsscol. Syd. 
Soc. 1893.— 46. Priestley. Art. "Hsematocele." Beynolds' System of Med. 1819.— 
47. Puech. De V Hematocele peri-uterine et de ses sources. Montpelier, 1858. — 48. 
Recamier. Lancette Fran(:aise, July 1831. — 49. Regnier. Bull. Soc. de med. prat. 
1892.-50. RouGET. Jour, de la Physiol, de Vhomme, etc. 1858. — 51. Routier. Annal. 
de gyn. Jany. 1890. —52. Scanzoni. Diseases of Women. American edit. — 53. 
ScHROEDER. Handbuch der Kvank. etc. etc, uud Arch. f. Gyn. Bd. y. — 54. Sbyfert. 
See TuckwelFs Essay. — 55. Simpson, Sir J. Y. Diseases of Women. — 56. Sutton, 
Bland. Med.-Chir. Trans. 1890. — 57. Tait, Lawson. Diseases of Women, 1889.— 



BENIGN GROWTHS OF THE UTERUS 561 

58. Tardieij. Annal. de hygiene, published 1854. — 59. Thornton, Knowslet. Obstet. 
Trans. 1889. —60. Tilt. Diseases of Women. — 61. Tuckwell. On Effusions of Blood 
in the Neighbourhood of the Uterus, 1863. —62. Veit. Centralblatt filr Gyn. 1891.-63. 
Velpeau. Eecherches sur les cavite's closes, 1847. — 64. Vigues. Des Tumeurs sanguines 
de Vexcav. pelv. 1850. — 65. Voberk. Bull, de la Soc.de Chir. 1851; and Gazette des 
hopit. 1855. — 66. VoisiN, Be V Hematocele retro-uterine, 1858. — 67. VonStrauch. St. 
Petersburger Med. Wochen. 1891. — 68. Weber, F. Berlin, klin. Wochen. Chir. No. 
1, 1873. — 69. Y7est. Diseases of Women.— 10. Williams (Sir John). "Serous Peri- 
metritis," Titans. Obstet. Soc. 1885. — 71. Winckel. Die Path, der Weibl. Sex. Org. 
1881; and Lehrbuch der Frank, 1892. — 72. Zweifel. Arch. Gyn. Bd. xxii. 

W. 0. p. 



BENIGN GEOWTHS OF THE UTEEUS 

The uterus is undoubtedly the most common seat of new growths in 
the human body. Exact statistics as to their relative frequency cannot 
be quoted; indeed, precise statistical evidence of the relative frequency of 
neoplasms generally must be untrustworthy. From the researches of 
V. Gurlt however, compiled from the Vienna Hospital Eeports, which 
embrace 15,880 cases of tumour, females exceeded males in the propor- 
tion of seven to three ; and of this large majority in the former, uterine 
growths accounted for 25 per cent, while the other sexual organs, includ- 
ing the mamma, contributed about 20 per cent. 

The cause of this great frequency of new growths in the uterus is 
unknown ; but when we consider the variety of its tissues, its constantly 
recurring periodic engorgements, and the enormous hypertrophy it under- 
goes during pregnancy, we may anticipate its special proneness to disease, 
and in particular to neoplasms. 

That these conditions enter into the causation of the new growths is 
proved by the extreme rarity of congenital growths, and by the infrequent 
development of neoplasms before puberty ; also after the menopause 
simple tumours rarely occur, and the malignant kinds in the great majority 
of instances are found in women who have previously borne children, 
and may be favoured by the bruising and laceration consequent upon 
parturition. 

Simple tumours, especially fibroids, were supposed to be more common 
in the coloured races ; but this assertion has lately been contradicted. 

Easy circumstances seem especially to be associated Avith the develop- 
ment and growth of uterine fibromyoma, in contradistinction to the 
preponderance of uterine cancer in the poor and badly nourished. 

The classification of uterine growths of a simple character may be 
most practically and simply considered by dividing them into two primary 
groups : (A) tumours of the muscular wall, and (B) tumours of the mucous 
lining. 

A. Tumours of the Muscular Wall are practically represented by 

2o 



562 SYSTEM OF GYNECOLOGY 

one variety, the fibromyoma ; these tumours, however, may undergo a 
large number of secondary changes that so transform their original struct- 
ure, that one is tempted to describe them severally as independent types 
of neoplasm. Some growths, such as the cystic, may occasionally, no 
doubt, develop as such; but in the absence of definite proof of this, 
and on account of their extreme rarity, it is more simple and practical 
to attribute them entirely to secondary changes in pre-existing fibroids. 

The Fibromyomas — also known as fibroid or fibrous tumours, myomas, 
leiomas, and hysteromas — are by far the most common of uterine new 
growths. They are stated by Bayle to occur in 20 per cent of all women 
over thirty -five years of age ; while in women of fifty, Klob (37) estimates 
their occurrence at 40 per cent. Fortunately these statistics were com- 
piled from an exhaustive and detailed examination of uteri after death, 
in the majority of which the growths were so small as to give rise to no 
inconvenience or any indication of their presence during life. 

It is, therefore, of much more practical interest to make an approxi- 
mate estimate of the percentage of women who suffer from pelvic 
symptoms due to these growths. For this purpose I have consulted the 
case-books of the Edinburgh Eoyal Infirmary, which show that of 2230 
gyngecological cases, in only 176 (8 per cent) was fibromyoma the assigned 
cause. The figures thus obtained must necessarily be considerably within 
the actual proportion, as only patients suffering from urgent symptoms 
are treated as in-patients ; while a large number of cases of fibroids are 
attended with minor symptoms. Further, as is well known, these tumours 
are more commonly met with in the more affluent classes which do not 
attend at hospitals. Yet when we compare the rarity of fibromyoma 
in gynaecological practice with the statistics of Klob and Bayle, based 
upon their presence in Avomen generally, it must be assumed that the 
proportion of fibroids, which give rise to any symptoms whatever, is 
exceedingly small. 

Fibromyomatous tumours are associated with the period of sexual 
activity. Their growth is practically confined to the years between 
puberty and the menopause, and it is doubtful if they ever originate 
before or after this period ; indeed, if uncomplicated by secondary changes, 
they cease to grow after the climacteric. In Winckel's tables two cases 
are quoted as occurring in women over seventy years of age ; and many 
cases are recorded in women over sixty. It is probable, however, that 
these were due to secondary changes occurring in pre-existing and un- 
noticed tumours, changes which are by no means an infrequent result of 
chronic oedema [see Fibrocystic Growths, p. 586]. A curious and inter- 
esting case is cited by Sutton, in which a tumour, supposed to be a fibroid, 
was present for ten years in the uterus of a childless widow, twice mar- 
ried, who had never menstruated, or shown any physiological evidence 
of ovulation. 

The earliest example cited is in a girl of ten years of age (26), but 
unfortunately no account is given of the microscopic structure of the 
growth or of menstruation. 



BENIGN GROWTHS OF THE UTERUS 563 

Opinion is divided as regards the influence of the sexual functions 
upon the development and growth of fibroniyoma ; but, strangely enough, 
this difference of opinion lies almost entirely between the pathologists on 
the one hand, and the gynaecologists on the other. The former maintain 
that these growths largely predominate in the unmarried, and Cohnheim 
(11) even asserts that sterility leads to their formation. Unfortunately, 
however, no statistics have been produced in support of this assertion. 
The majority of gynaecologists entertain an entirely opposite opinion; and 
most trustworthy investigators — such as Schroeder, Winckel, Gusserow, 
and others — have adduced overwhelming evidence on this side of the 
argument. Thus Schroeder found 614 married women in 792 cases; 
and Winckel and Gusserow consider the proportion of the married to 
the single to be as two to one. 

It seems difficult at first to reconcile such conflicting statements ; but 
on consideration of the very different sources of information — namely, 
post-mortem examinations and clinical experience — the inference appears 
that the great majority of tumours originate independently of sexual 
irritation, at least so far as intercourse is concerned; but that their sub- 
sequent growth is so favoured by its indulgence that symptoms and 
signs of the presence of the tumour more frequently arise. 

The influence of fibroids upon child-bearing has at all times been a 
fruitful source of discussion, sterility being regarded by some observers 
as an actual cause of their development (Emmet). Others look upon 
sterility as a consequence. In support of the latter opinion almost in- 
controvertible evidence has been brought forward by West, Scanzoni, 
M'Clintock, Winckel, Schroeder, and many others, whose combined statis- 
tics show 621 cases of absolute sterility in 2035 cases of fibroids ; that 
is to say, about 30 per cent were childless. When this is compared with 
the average sterility in women generally (10 per cent) (17), one is com- 
pelled to admit that they exercise a marked preventive infiuence on con- 
ception. That the sterility is due to the tumours, and not the tumour 
to the sterility, is strikingly supported by the important statistics of 
relative sterility as quoted by Winckel and Susserot (61). These afford 
convincing proof of the undoubted preventive effect of fibromyomata 
upon child-bearing. Their combined cases show that 99 fruitful women 
with fibroids bore only 276 children, an average of 2''^\ the normal 
average of children to each mother in the same locality being 4-5. 

West found that of thirty-six fruitful women with fibroids, the average 
number of children to each mother was scared}^ two ; twenty of the 
thirty-six mothers had but one child each, a most striking contrast to 
the statistics of Ansell, which show that normally only one in thirteen 
mothers have but one child. 

The statistics of the effect of sexual excitement and child-bearing on 
the development and growth of fibroids seem to lead to the following 
conclusions : — 

(1) That fibromyoma originates in the majority of instances in- 
dependently of marriage and pregnancy. 



564 SYSTEM OF GYNECOLOGY 

(2) That sexual excitement in marriage favours their growth. 

(3) That they tend to prevent child-bearing. 

(4) That pregnancy seems to promote their growth to a great extent, 
so that future conception is in many cases prevented, and signs and 
symptoms of their presence are manifested. It will be shown, in review- 
ing in detail the subject of the effect of fibroids on pregnancy, that 
sterility is further promoted by the preventive effect of these tumours 
on the growth of the ovum. 

Patliological Anatomy. — Eibromyomas may be found either in the 
body or in the cervix uteri ; in the former site, however, they greatly 
predominate, 4 per cent only occur in the cervix. They are said to occur 
more frequently in the posterior than in the anterior wall, although from 
experience I cannot corroborate this statement. 

Their origin has been and is still a source of much speculation. Some 
attribute them to the organisation of blood accidentally extravasated. 
Others state that they have found bacterial colonisation as the nucleus of 
the growth, a statement effectually disproved by Marey. Klebs attributes 
them to a proliferation of the connective and muscular tissues of blood- 
vessels, a theory which is supported by the general deposition of the 
muscular bundles parallel to the vessels in the tumour. The actual 
histogenesis has yet to be proved. 

In size these growths vary from less than a pea upwards, and have 
been recorded as reaching the enormous weight of 140 lbs. (32). 

They are most frequently multiple, and in but very few instances 
of apparently solitary tumours will a minute examination fail to detect 
other small nodules in the uterine wall. In some cases as many as fifty 
independent tumours may be found growing in the same uterus. A 
marked exception to the general rule of multiplicity is to be found in 
the case of the so-called oedematous fibroid, which in the large majority 
of instances is solitary. 

Formed from the same elements as the uterine wall, the gross 
characters of fibromyoma vary considerably according to the relative 
excess of muscular or fibrous tissue in their structure ; usually these 
growths are of a firmer consistence than the uterine wall from which 
they spring. In some cases, when composed largely of muscular tissue, 
they are soft, and give the impression of a simple hyperplasia of the 
uterine tissues. On section the soft varieties have a reddish pink 
appearance, and to the naked eye are more uniform in structure than 
the commoner hard variety. The latter on section appear pinky white, 
with wavy, glistening, whitish bands coursing in every direction, but with 
a decided tendency to form whorls round individual centres, an appear- 
ance which gives rise to the not inapt comparison to "a ball of wool." 
This characteristic appearance is due to the mode of growth of the 
tumour, the muscular tissue closely following and running parallel to the 
blood-vessels. Thus they closely simulate development from a number of 
distinct centres ; but their origin from a single focus is proved by other 
facts, such as the extreme rarity of more than one nodule within the 



BENIGN GROWTHS OF THE UTERUS 565 

same capsule, and the smooth, spherical form of all nodules free from 
irregular pressure. The cut surface of fresh sections is uneven, the 
elasticity of the fibrous tissue causing the softer muscular bundles to 
bulge externally. 

The growth is usually enveloped in a false capsule derived from the 
uterine tissues, which have undergone marked compression changes from 
the ever increasing and constant circumferential pressure caused by the 
developing tumour. 

As the capsule is formed by the surrounding tissues, it varies in 
thickness according to the original site of development of the tumour. 
Thus when the growth originates in the middle layer of the uterine wall, 
the surrounding capsule will be thick and well formed ; but, if the 
tumour develop in the external or internal layers of the uterine mus- 
cle, the intervening muscular layers between it and the superimpose 
peritoneum, or mucosa, must necessarily be but scanty, and the capsule 
correspondingly thin; indeed, in some cases the muscular capsule is 
entirely absent, the tumour being covered by the peritoneum or mucosa 
alone. 

Between the tumour and the so-called capsule there is a layer of 
loose connective tissue in which the growth is embedded, that in some 
cases allows of its ready enucleation. In other instances, however, there 
are many strong muscular and fibrous bands passing between the growth 
proper and the capsular wall, which prevent a ready enucleation ; in 
some of the softer tumours these intervening bands are so numerous as 
to obscure any line of demarcation between the tumour and surround- 
ing muscle, and the whole mass thus appears to be a simple hyperplasia 
of the uterine wall. 

In the capsule, and embedded in the loose connective tissue between 
it and the tumour, may be seen the numerous and large blood-vessels 
surrounding the tumour, from which it derives its nourishment. These 
do not penetrate the substance of the growth to any great depth, and 
thus sections of Avell-formed vessels are but seldom found away from 
the periphery. 

Their vascularity is but slight in comparison to that of the uterine 
wall from w^hich they spring, as is well shown in Fig. 141, taken from a 
preparation of an injected uterus with fibroid. 

In the harder varieties blood-vessels are extremely scanty, especially 
towards the centre of the growth ; but in the softer growths they are 
much more numerous. They are rarely well formed, however, and 
appear rather to be of the nature of sinuses. The blood-supply, there- 
fore, is usually but scanty, and the circulation at the best slow and 
difficult. 

Normally of a smooth, round, uniform shape, the spherical contour 
of the original nodule may become much modified by the effects of 
irregular pressure, or by the development of secondary nodules in its 
capsule. 

When examined microscopically these tumours are found to be com- 



566 



SYSTEM OF GYNECOLOGY 



posed entirely of muscular and connective tissue elements, which vary 
widely in relative quantity. When young and in rapid growth the 
muscular tissue, as a rule, largely preponderates ; but it would appear 
that in the majority of cases the connective fibrous tissue slowly increases 
at the expense of the muscular, which occasionally it almost entirely 
replaces. It is thus evident that no constant appearance can be assigned 

to the growth, as its structure varies 
within broad limits. It is usual in young 
and rapidly growing tumours to find the 
muscular elements preponderating; but 
although I have examined a large number 
of tumours, I have never yet seen an 
example in which (as some authors main- 
tain) the fibrous tissue is so scant a pro- 
portion that it may be neglected, and 
the tumour reckoned as a pure myoma. 
The distribution of the tissues is 
extremely various ; in some cases of soft 
growths (Fig. 142) the connective tissue 
may be seen in the form of definite tra- 
beculse passing from the capsule, and 
splitting the muscle bundles into distinct 
groups ; these trabeculae at the same time 
carry the blood-vessels. More frequently 
the connective tissue and muscular bun- 
dles are indefinitely intermixed with- 
out any apparent regularity in their 
distribution, and according to the pro- 
portion of each so is the tumour soft 
or hard (Figs. 142 and 143). 

The appearances presented by the 
muscle bundles on section vary greatly 
as is to be expected from their irregular 
disposition throughout the growth, run- 
ning parallel as they do to the blood- 
vessels. When cut longitudinally, their elongated shape and rod-like 
nuclei are at once apparent and characteristic ; while on direct trans- 
verse section they closely simulate groups of round cells. When 
obliquely severed they may have the appearance of the cells of a sarcoma. 
Between the muscle bundles may be seen many spaces in the con- 
nective tissue, only here and there lined by endothelium, and forming 
true lymph channels. Nerves terminating in the individual muscle cells 
have been described by Hertz. 

So far as histological examination shows, it would appear that these 
growths originate and develop by the proliferation of muscle fibres 
around the capillaries, the connective tissue at the same time being 
slightly increased. In this manner they may continue to grow rapidly 




Fig. 141. — Injected uterus with fibroid, 
showing numerous large blood sinuses 
in uterine wall. From specimen, Ana- 
tomical Museum, Edinburgh. 



BENIGN GROWTHS OF THE UTERUS 



567 



to a large size, and are known as soft tumours. In the majority of 
instances, however, the fibrous connective tissue would seem slowly but 
surely to increase at the expense of the muscular elements which it 
displaces ; the tumour thus becomes harder and more fibrous, the blood- 
vessels are encroached upon and even obliterated, while the muscular 
cells themselves are only to be recognised in groups here and there. 
This fibrous tissue development tends to take place more in the older 
and central portions of the 
growth, which are less vas- 
cular than in the periphery 
of the tumour, this latter 
portion being more freely 
nourished by the vessels 
which everywhere pass to it 
from the capsule. 

The rate of growth, then, 
must depend almost entirely 
on active proliferation of the 
muscular elements at the 
periphery. When the fibrous 
tissue predominates the in- 
crease is extremely slow, and 
in many cases ceases alto- 
gether ; while the rapidly 
growing tumour is largely 
composed of muscle, and is 
thus softer and more vascular 
than the hard, slow-growing, 
or even stationary type. On purely pathological grounds it is, therefore, 
impossible to divide these tumours into fibrous and myomatous varieties, 
as the one may insensibly pass into the other. The term fibromyoma 
must on these grounds be considered as the only strict scientific designa- 
tion which embraces all varieties. 

From a clinical aspect, however, it is well to recognise the two types 
of soft and hard tumours, as they vary greatly in their rate of growth, 
prognosis, diagnosis, and treatment. 

I have said that all fibromyomas originate in the muscular layers of 
the uterine wall ; yet the site of their development and the subsequent 
direction of their growth are of the utmost importance. Their clinical 
aspects and subsequent course differ so much with their situation, that 
for descriptive purposes it is necessary to distinguish them ; and for 
this purpose they are clinically classified as Submucous, Subperitoneal, 
and Interstitial (Fig. 144). 

Submucous Tumours. — These are represented by two varieties dis- 
tinguished by the presence or absence of a muscular capsule. The 
"free" or non-capsulated variety is usually developed from the in- 
ternal layers of the uterine muscle, and is thus from its origin closely 




Fig. 142. — Microscopic section of soft fibromyoma, show- 
ing large muscle areas surrounded by connective tissue 
trabeculae carrying the blood-vessels 



x40. 



568 



SYSTEM OF GYNECOLOGY 



connected with the superimposed mucosa, which actually forms the 
false capsule from which it derives its nourishment (Fig. 145, 1 and 
1a). The encapsulated variety, on the other hand, is developed in the 
middle layers of the uterine muscle, and its false capsule is thus formed 
by muscular tissue ; but at the same time, as its direction of growth is 
towards the uterine cavity, it bulges the mucosa in front of it (Fig. 145, 
2 and 2a), and on a superficial examination seems identical in appearance 
with the " free " variety (Fig. 145). Though thus apparently similar, 
their subsequent growth and attachment to the uterus are of sufficient 
practical importance to warrant distinction. 




Fig. 143. — Microscopic section of common fibromyoma, showing muscular and connective tissues 

and blood sinus, x 120. 



In some cases a primary encapsulated tumour may become subse- 
quently " free " by the attenuation and destruction of its muscular 
capsule by pressure. 

The uterus, being highly intolerant of foreign bodies in its wall, and 
especially in its cavity, attempts by contraction to expel them. Thus 
both varieties of submucous tumours are prone to be driven more and 
more into the uterine cavity, and to become more or less stalked or 
pedunculated, so as to form what are known as " submucous polypi " 
(Fig. 146). 

That this process of expulsion must be easier in the free variety is 
evident, as there is no superimposed uterine wall or capsule to prevent 
its occurrence. Should pedunculation occur, the pedicle or uterine attach- 
ment must vary considerably in the two types ; in the " free " variety 
it will be merely represented by the attenuated mucosa, while in the 
encapsulated type the muscular capsule is continuous with the uterine 



BENIGN GROWTHS OF THE UTERUS 



569 



muscle. In some instances the latter may become so attenuated as to 
offer but a feeble union with, the uterus ; but in many cases it remains 
well marked and firm. It will thus be seen that the removal of the 
former is usually easy ; of the latter it may be an affair of consider- 
able trouble. 




Fig. 144. — Section of fibroid uterus, from specimen in my museum, showing — 1, Polj'pus ; 2, intersti- 
tial fibroids ; 3, subserous fibroids ; 4, cervical fibroids. 



The encapsulated tumours grow to a much larger size than the free ; 
this is due to the preservation of the capsular circulation from which 
alone fibromyomas are nourished. I have, however, met with " free " 
polypi as large as a foetal head, the growth being nourished by large 
vessels situated in the highly vascular mucosa ; this indeed in these 
cases may be considered as the capsule. 

In many instances the muscular capsule resists the attempts of the 
uterine contractions to expel the growth; thus pedunculation is pre- 
vented, although the tumour may bulge more or less into the uterine 



570 



SYSTEM OF GYNECOLOGY 



cavity : this form is known as the true sessile submucous fibromyoma. 
A submucous polypus can only be considered as the final stage of the 
attempt of the womb to expel tumours primarily interstitial or sub- 
mucous. 

Both sessile and pedunculated varieties necessarily cause enlargement 
of the uterine cavity, and greatly increase the vascularity of the organ. 

At the same time, by stimulating 

the uterine contractions for their 
expulsion, they lead to much gen- 
eral increase in the thickness of the 
uterine wall ; so marked, indeed, is 
this hypertrophy in some cases, 
that it may closely simulate the 
pregnant organ in the earlier months 
of gestation, a similarity which has 
given rise to the descriptive term, 
"grossesse fibreuse," used by Guyon. 
Primarily the entire mucous 
membrane may become congested, 
but especially that portion which 
actually covers the tumour. This 
is well shown in the injected uterus 
with contained polypus in the 
Anatomical Museum of Edinburgh 
University (see Fig. 146). From 
this site it is probable that the 
copious ha3morrhages proceed which 
are associated with this variety 
of tumour. 

It is averred by Wyder that 
there is constantly an inflammatory connective tissue thickening of the 
entire mucosa : this process in many cases which I have carefully ex- 
amined I failed to detect, although in others it was well marked. In 
certain cases a glandular endometritis is associated with fibromyoma, 
which accounts for the severe accompanying leucorrhoea frequently 
complained of. 

Atrophy, and even ulceration of the superimposed mucosa, are occa- 
sionally met with as the result of pressure from extrusion of the tumour ; 
and should the growth, as in the " free ^^ variety of polypus, derive its 
nourishment from the vessels of the mucosa, grave secondary changes, 
such as sloughing and gangrene, are likely to result. From the com- 
pression exercised by the contraction of the uterus, the circulation 
through a polypus is frequently so far arrested that it becomes more or 
less infiltrated with serum. This, if acute, may result in death, slough- 
ing, or gangrene ; but if slow it does not entirely stop the nutrition of 
the polypus growth, though it imparts to it a soft elastic consistence 
which may lead to its being mistaken for a cyst (chronic oedema). 




Fig. 145. —Diagram of growth of uterine fibroids. 
1, 1a, Free submucous ; 2, 2a, encapsulated 
submucous ; 3, encapsulated subserous ; 4, 
free subserous. 



BENIGN GROWTHS OF THE UTERUS 



571 



Occasionally actual cystic change is met with in these tumours (see 
p. f)%^). As the result of uterine contractions and of gravitation, all 
uterine polypi tend to descend towards the vagina, and their pedicles 
become more and more elongated and attenuated (Fig. 147). This may 
go so far that they may project from the vulva, though still attached to 
the uterus (Cullingworth). 

Expulsion into the vagina may be extremely sudden, but usually it 
is slow. In the case of the so-called '■'■ intermittent polypus " the os 
uteri becomes dilated at intervals, and the growth may then be felt 
projecting through it. This periodic dilatation is nearly always met 
with during a menstrual period. 




Fig. 146. — Encapsulated submucous fibroid becoming polypoidal. From specimen of injected uterus 
and fibroid, Anatomical Museum, Edinburgh. Half-size. 1, Uterine wall ; 2, capsule ; 3, tumour. 



Complete separation and expulsion, though by no means unknown, 
are rarer events than might be supposed. 

Partial inversion of the uterus not infrequently results from the too 
rapid expulsion of these growths ; and several cases of total inversion 
have been recorded. 

From pressure on the surrounding uterine and vaginal mucosa, ulcera- 
tion and subsequent adhesions may form ; and through these secondary 
attachments the nutrition of the tumour may be maintained, even after 
total separation from its original site. 

During expulsion the polypus may be so firmly gripped by the 
cervix, that a slough of the entire intravaginal portion results. The 
gangrenous process may, in these cases, spread upwards through the 
entire tumour, when it frequently terminates fatally. 

Not only, as I have said, may the uniform spherical shape, and 



572 SYSTEM OF GYNECOLOGY 

smoottL surface of a polypus, become mucli altered in contour from 
surrounding pressure and cervical constriction, but ulceration, and 
consequent slougliing of the capsule may simulate closely a cancerous 
mass, and may be mistaken for it. 

Symptoms. — The characteristic symptom of the submucous fibroid is 
uterine hsemorrhage. This occurs at a very early stage in almost every 
case, and thus this variety of tumour comes much more frequently under 
the notice of the practitioner at an early period than the subserous and 
interstitial varieties, which rarely give any indication of their presence 
till they have attained considerable dimensions. 

The haemorrhage may vary greatly in degree ; but the blood loss, as 
a rule, closely corresponds with one of two factors, namely, the size of 

the growth or the extent of its pedun- 
^„^-'"^' /' "^'^----^^ culation. Thus, if a small growth the 
V ' size of a walnut become polypoidal, it 

\ /^ may give rise to bleeding as severe as 

\ / that from a large sessile tumour. 

\ : , In a typical case of submucous fibroid 

\ -^ .■ the clinical picture is suggestive and 

' ' M \ characteristic ; and shows a history of 

r^' --"^f 'W "^— > slowly increasing menorrhagia, with 
^^"^ " " ^ ^^ - - -^ consequent anaemia and debility. The 
-^ former, at first but slight and tempo- 

y ' , rarily confined to the menstrual and 

/ ^\ immediate post-menstrual period, be- 

/ \ comes more severe and continuous ; 

\. ' intermenstrual bleeding follows in due 

\^ J course, and the haemorrhage eventually 

""^-^-^^ ^____ __^^ becomes almost constant, and the pa- 

Fig. 147. -Submucous polypus. From sped- ^ieut is rcduccd to the utmost extremity, 
men, College of Surgeons' Museum, Variations from this extreme though 

Edinburgh. Half-size. i • _r i n , 

by no means mirequent course oi events 
are often met with. The slowly increasing menorrhagia may rapidly or 
suddenly give place to copious metrorrhagia ; and the character of the 
haemorrhage may vary from a prolonged and constant oozing to sudden 
gushes of alarming magnitude. Floodings and copious intermenstrual 
bleedings are very commonly associated with polypi, and are probably 
due to lacerations of the veins in the pedicle. In some instances these 
must be looked upon as the only source of excessive bleeding, as the 
menstrual periods are frequently regular and quite normal in amount, 
except when broken occasionally, after many months interval, by a 
sudden and profuse haemorrhage. In some cases there may be amenor- 
rhoea for months' duration, following a severe bleeding from an intra- 
uterine polypus. 

The source of the bleeding is twofold — from the mucosa immediately 
covering the tumour, and from the general lining of the uterus. Probably 
on most occasions they are simultaneous, but it is certain that either ma^y 
act separately. 



BENIGN GROWTHS OF THE UTERUS 573 

The most active primary site of the haemorrhage is undoubtedly the 
mucosa covering the growth; it is always extremely vascular, but is 
especially so in the ''' free " variety, as it contains the venous sinuses 
from which the growth is nourished. In some cases, where from pressure 
the mucosa becomes atrophied, and its vascularity completely destroyed, 
the menorrhagia may cease. Should bleeding here continue, as it most 
frequently does, the source of the haemorrhage will now be found in the 
general mucous lining of the uterine cavity, which is usually thickened 
and congested, as the result of irritation and increased uterine contraction. 

That complete atrophy and absence of vascularity of the superim- 
posed mucosa occurs, may frequently be observed in ulceration of the 
lower pole of a polypus without associated haemorrhage. 

The metrorrhagia is in many cases due to the rupture of veins in the 
superimposed vascular mucosa, a condition which accounts for the sud- 
denness and occasional enormous amount of the blood loss. Indeed, 
fatal bleedings from this source have been noted by Cruveilhier and 
Matthews Duncan (18). 

As I have already shown, rupture of the venous sinuses in the 
pedicle of a polypus may account for those irregular and profuse 
haemorrhages which may be the only indication of its presence. This 
is due to actual tearing, as the expulsive action of the uterus drives the 
tumour outwards. 

The increased haemorrhage at the menstrual epochs, which is asso- 
ciated with fibromyoma, frequently remains moderate in degree through- 
out the entire menstrual life of the patient ; there being no tendency to 
aggravation or to metrorrhagia. This obtains only in tumours which 
remain small and inactive. 

Associated Avith the sjanptoms of haemorrhage there is, in a small 
proportion of cases, a constant and abundant watery leucorrhoea, directly 
due to concurrent glandular endometritis. When present it effectually 
prevents the restoration of strength so necessary after a prolonged or 
profuse period. 

Pain in this variety, as indeed in all varieties of fibromyoma, is a 
most variable symptom. When of considerable size the tumour usually 
produces a sense of weight and bearing down in the pelvis ; and fre- 
quently, from the pressure of the enlarged uterus on adjacent structures, 
symptoms similar to those described under the subserous variety are 
experienced. Eetention of urine is stated by Hardie to have been caused 
by the pressure of a small tumour on the neck of the bladder through 
the anterior uterine wall. 

Occasionally intense and continuous pain is present with small 
tumours, while with others, which may distend the uterus to the size 
of a six months' pregnancy, little or no discomfort is felt. 

Dysmenorrhoea is of fairly frequent occurrence ; and is due either to 
obstruction of the flow of blood from the uterus by the tumour (mechanical), 
or to the uterine contractions which occur during menstruation, and which, 
under the influence of the tumour in its wall, are irregular and painful. 



574 SYSTEM OF GYNECOLOGY 

Pains of a labour-like nature are constantly associated with polypi, and 
are due to uterine contractions attempting to expel the growth. Reflex 
pains and neuroses of all varieties, and in every situation, may be present. 

Sterility is common in this variety ; indeed, conception seldom oc- 
curs. Should it do so, however, the continuance of gestation is usually 
interfered with (see p. 593). 

The menopause is in the majority of cases much delayed. 

Diagnosis. — The detection of submucous fibroids depends almost 
entirely on the history of uterine haemorrhage, associated with physical 
signs of enlargement of the uterus and its cavity. The increase of the 
uterus as a whole is only to be made out by careful bimanual examina- 
tion, when it will be found symmetrically enlarged to a greater or less 
extent, according to the dimensions of the neoplasm within. It may 
closely simulate pregnancy, but the harder consistence and the history 
of haemorrhage are usually sufficient to distinguish it. Enlargement of 
the uterine cavity is to be diagnosed with the uterine sound, which, 
however, on account of the distortion of the canal by the tumour, in 
some cases can only be passed with difficulty. Undue force in the at- 
tempt must be carefully avoided, as laceration of the capsule may bring 
about serious consequences. Therefore, if much resistance be met with, 
a flexible gum elastic or whalebone bougie should be substituted, and 
will generally be found very serviceable. 

The conditions most apt to be mistaken for fibroid tumour are sub- 
involution, or chronic metritis with endometritis ; but in these cases direct 
derivation from a previous pregnancy, and associated chronic cervicitis, 
aid us in the diagnosis. Should the distinction be doubtful, nothing 
remains but direct digital examination of the uterine cavity, when the 
absence or presence of the tumour will be ascertained. The intra-uterine 
examination may, in many cases, be performed easily during menstruation, 
when the softened and gaping cervix offers but little resistance to the 
introduction of the finger ; otherwise artificial dilatation must be used. 

Polypoidal tumours, when completely intra-uterine, are to be 
diagnosed in a similar manner: but being usually associated with 
paroxysms of " labour-like " pains and metrorrhagia, a further valuable 
hint in their diagnosis is afforded. Occasionally the intravaginal cervix 
will be found much shortened ; in these cases examination during a 
menstrual period will seldom fail to reveal a presenting tumour, the 
so-called 'intermittent polypus." 

Submucous polypi of the body of the uterus, when intravaginal, are 
usually easy of diagnosis by local digital examination, as the pedicle is 
felt to pass upwards through the cervical canal, thus distinguishing 
them from cervical growths. From their large size, however, and also 
from adhesions to the vaginal and cervical walls, a decision is sometimes 
impossible. 

As the result of tight constriction by the cervix, or ulceration of their 
capsule, polypi may become gangrenous, and emit a most offensive dis- 
charge ; while the tissue of the tumour itself becomes broken down and 



BENIGN GROWTHS OF THE UTERUS 



575 



necrosed. In this condition they are not infrequently mistaken for 
epithelioma; usually, however, the finger can be passed beyond the 
rough irregular mass, when the upper surface will be found smooth, a 
condition which never exists in malignant disease. Further, digital 
examination is seldom followed by the characteristic haemorrhage of 
malignant growth. 

The diagnosis of polypi from inversion of the uterus can readily be 
made by the introduction of the sound into the uterine cavity. In 
the former case it will pass farther than the normal 2\ inches ; if the 
uterus be inverted the normal length of the uterine cavity must be 
diminished. Careful bimanual examination will also demonstrate inver- 
sion, by the absence of the uterine body and fundus, or the cup-shaped 
uterine depression. 

Simple as these distinctions may appear, errors of diagnosis, leading 
to grave mishaps in operation, have been made by eminent surgeons. 




Fig. 148. — Uterus, showing subperitoneal fibroids. From specimen ; half-size. 



Subperitoneal or Subserous Fibromyoma. — In these we have a similar 
origin and mode of growth to the submucous, v^rith the sole distinction 
that the primary hbroid nodule either originates in the external layers 
of the uterine muscle, and grows outwards under the peritoneum ; or is 
developed in the middle layers, and grows, or is driven, in the same 
outward direction. 

That there are "free" and encapsulated varieties, as in the sub- 
mucous, is true ; but the former rarely grow to dimensions sufficient to 
cause symptoms. When primarily free they seldom grow larger than 
a small Tangerine orange, but from attenuation of the capsule large 
primarily encapsulated growths may be found apparently " free." 

It is probable that the slowness of growth in the " free " subperitoneal 
variety, as compared with the submucous, is due to want of nutrition ; as 
the vascularity of the peritoneal covering of the former is but slight 
as compared with the highly vascular mucosa. 



576 SYSTEM OF GYNECOLOGY 

The encapsulated variety, on the other hand, grow to enormous 
dimensions, there being no resistance to their growth comparable to 
that met with by the submucous, which has not only to distend the 
uterine cavity, but also to withstand the compressing force of uterine 
contraction. 

Their attachment to the uterus naturally varies within wide limits ; 
but usually in tumours of large size it is of considerable thickness : 
although cases are not uncommon where large growths have pedicles no 
thicker than a goose-quill. In certain instances the pedicle is so attenu- 
ated that without any apparent cause the tumour may become actually 
separated from the uterus. 

When the pedicle is long and thin, such a degree of mobility indepen- 
dent of the uterus may be obtained, that in their signs these tumours may 
closely simulate ovarian tumours ; frequently, indeed, they are so regarded 
till laparotomy makes clear the diagnosis. This difficulty in diagnosis is 
still further increased when secondary cystic degeneration is present, a 
variety of change frequently met with in stalked subperitoneal tumours. 

The direction of growth of large subserous tumours is fortunately 
most frequently upwards into the abdominal cavity, although in some 
instances they remain pelvic ; this may be due either to accidental incar- 
ceration or to burrowing among the tissues of the pelvis, with consequent 
splitting of the layers of the broad ligaments. This latter most serious 
condition is generally met with in tumours which spring from the lower 
part of the uterine body or supravaginal cervix. 

Subperitoneal fibroids are usually associated with more or less en- 
largement of the uterus, though the degree of it necessarily depends on 
the extent of the attachment of the growth. I have, however, seen a 
tumour weighing over 7 lbs. attached by a narrow pedicle to a uterus 
more atrophied than enlarged. Thorburn describes a similar case. 
He removed a tumour of 12 lbs. from a small atrophied uterus. 

In a similar manner the cavity of the uterus is more or less enlarged 
according to the degree of attachment of the growth. With a narrow 
pedicle this may be but fractional, and after the menopause the cavity 
may be found actually shortened though a large tumour be present. 

Large tumours attached to the fundus may, by traction from upward 
growth, enormously increase the length of the cavity, and at the same 
time attenuate the uterus as a whole. Such a case has been described 
by Tinns, where the uterus was so pulled out, that it was repre- 
sented by a mere muscular cord, the canal being completely obliterated 
for a distance of two inches. Virchow avers that traction may be so 
extreme that complete separation of the body from the cervix may 
occur. 

From localised peritonitis and subsequent adhesions, secondary attach- 
ments may arise; these have been known to be the sole means of 
nourishment of large tumours which, through laceration of the pedicle, 
have become separated from their original site of development. 

The position of the uterus is much modified by subserous growths; 



BENIGN GROWTHS OF THE UTERUS 577 

as I have said above, it may be drawn up ; in other cases, however, the 
increased weight may cause actual prolapse. Other displacements 
naturally occur according to the position of the growth. If the tumour 
be large and pelvic, and lie posteriorly, the uterus may be tilted up- 
wards above the symphysis pubis as in hsematocele ; while if small and 
growing from the fundus, retroflexion is a common consequence. In a 
similar manner when laterally placed, the uterus may be pushed to one 
or other side. 

Symptoms. — This variety of fibromyoma, unlike the submucous, has 
no individual and characteristic symptom, and in many instances grows 
to considerable dimensions without causing the slightest inconvenience. 
Frequently even large tumours of this description are casually found on 
examination of the abdomen for symptoms in no way referable to the pelvis. 

Should symptoms due to their presence be complained of, these in 
the majority of cases are the result of mechanical effects upon the uterus 
or ad j acent structures. Thus when small they may cause displacements of 
the uterus, with their associated discomforts — many flexions and versions 
of the organ are due to this cause. When larger they give rise to press- 
ure symptoms which naturally vary according to their size and position. 

By far the most frequent and important symptoms are the effects of 
pressure on the urinary system, which may be affected in many ways. 
Thus derangements in micturition are extremely common, and vary 
with the site and size of the tumour. If seated on the anterior wall of 
the uterine body they tend to prevent easy distension of the bladder, 
and from their actual weight cause frequent micturition. When situated 
low on the anterior wall they early give rise to extremely painful and 
distressing bladder troubles, such as difficulty in urination, and even to 
complete retention. 

When large, and incarcerated in the true pelvis, they not only tend to 
give rise to severe bladder discomforts such as urinary retention, dysuria, 
and cystitis, but from actual pressure on the ureters they may cause 
renal complications of the most dangerous character. Cases have 
been recorded where suppurative pyelitis and albuminuria have been 
cured after the removal of fibroids (Cabot ; Porak ; Skene) ; and 
doubtless many cases of overlooked kidney complications may account 
for fatal results after operation, as shown by Pozzi. In all cases of 
large fibroids special examination should be made of the urine. 

Pressure on the rectum, though more uncommon, may cause obstinate 
constipation and severe tenesmus. Interference with the pelvic circula- 
tion, from pressure on the veins, may be associated with haemorrhoids, 
varicose veins of the vulva, and occasionally, if exaggerated, with oedema 
of the lower extremities. 

From the increased vascularity of the pelvis due to the presence of 
the tumour and the associated impairment of venous return by increased 
intra-abdominal pressure, a bluish discoloration of the vulva may fre- 
quently be noted, analogous to Jacquemier's sign of pregnancy. 

Pressure on the sacral nerves is frequently associated with agonising 

2p 



578 SYSTEM OF GYNAECOLOGY 

pains in tlie back and legs ; while irritation of the sympathetic ganglia 
may cause vomiting and other reflex neuroses of indefinite characters. 
It will thus be evident how terrible may be the sufferings from a large 
intrapelvic fibroid. 

Compression and irritation of the peritoneum may cause localised 
peritonitis, with subsequent adhesions ; in some rare cases ascites has 
been noted. Actual sloughing and gangrene of the pelvic soft parts may 
occur from incarcerated tumours. Fortunately, however, the tendency of 
subperitoneal tumours is to grow upwards into the abdominal cavity ; yet 
here, according to their size and position, they may give rise to pressure 
symptoms of more or less severity. Usually these are extremely slight, 
unless the tumour be of enormous dimensions. When freely movable 
severe sickness and other reflex phenomena may be complained of. From 
the increased intra-abdominal pressure causing difficulty in the abdominal 
circulation generally, and also from the increased blood-supply necessary 
for the large tumour itself, a severe strain is thrown on the heart, which 
is therefore hypertrophied as in pregnancy. Uterine hsemorrhage, the 
outstanding feature of the submucous variety, is but seldom present with 
subserous growths ; but in some cases from associated pelvic congestion, 
metritis and endometritis, or the presence of other small fibroid nodules 
dwarfed by the large growth, bleeding may form a marked symptom. 

The diagnosis of subperitoneal fibroids is at times extremely simple ; 
on the other hand it may be surrounded with difliculties which make 
absolute certainty impossible. This is in great part accounted for by the 
absence of any specific symptom or sign, such as the haemorrhage and the 
uterine enlargement which we find in the submucous varieties. As we 
have already seen the uterus may or may not be enlarged ; in like man- 
ner haemorrhage, both menorrhagic and metrorrhagic, are as frequently 
absent as present : indeed, the symptoms of a given case may simulate 
those of other pathological conditions, which indeed often present physical 
signs almost identical. In some cases it is only by careful bimanual pal- 
pation that the presence of any growth can be recognised ; and in many 
a differential diagnosis, even in the hands of most competent observers, 
can only be provisional. 

For the sake of simplifying the diagnosis it may be well to classify 
these growths as of three types : — 

1. Those of the fundus and anterior and posterior walls of the body 
of the uterus, which tend to become pedunculated and grow upwards into 
the abdominal cavity. 2. Those of the side walls of the uterus which 
split the layers of the broad ligament. 3. Those of the lower part of the 
uterus which grow downwards into the pelvis — incarcerated tumours. 

The diagnosis of large tumours of the first group is usually easy 
when the attachment to the uterus is well marked ; for by the bimanual 
examination their origin from the uterus can be distinctly felt, and the 
two structures will be found to move simultaneously. When the pedicle 
of attachment is long and thin the diagnosis is much more difficult, as the 
uterus may be moved independently of the growth. When small it may 



BENIGN GROWTHS OF THE UTERUS 579 

sometimes be difficult to decide, by simple palpation, from which wall 
of the uterus a tumour springs, as the tumour and the fundus may appear 
similar in size and consistence. In these cases, however, the passage 
of the sound into the uterine cavity will decide the matter at once. 

A small growth on the posterior uterine wall is most easily palpated 
by rectal examination, with simultaneous dragging downwards of the 
uterus by means of a volsella. In this situation a small fibroid may be 
mistaken for an ovary, prolapsed and fixed in the retro-uterine pouch ; 
by a similar method of examination the absence of tenderness on press- 
ure, and the presence of the ovaries in another situation can be ascer- 
tained, and the exact condition determined. 

When associated with surrounding inflammatory deposit, the diag- 
nosis of small fibroids is extremely difficult and often impossible. 

Occasionally small tumours of the lower part of the anterior uterine 
wall are extremely difficult to detect, though, nevertheless, they may 
give rise to most distressing urinary symptoms. Digital examination 
by the urethra should in these cases be practised, as in many cases by 
this means alone a differential diagnosis can be obtained. 

Increase in the size of the uterine cavity is usually present when the 
uterine attachment of the tumour is well marked, although in rare cases 
large tumours have been found with a uterus distinctly atrophied. 

When situated between the layers of the broad ligament and fixed, 
and at the same time displacing the uterus to one or other side of the 
pelvis, these tumours may be confounded with morbid tubal enlarge- 
ments and cellulitic deposits. Under these circumstances the history 
of the case, the even contour of the mass, and the comparative absence 
of pain on pressure, tend to remove the obscurity in diagnosis. 

Tubal gestation, with a history of irregular and profuse uterine 
hsemorrhages, may be distinguished by the softness of the uterus and 
the attached swelling, the rapidity of its development, and the presence 
of other signs of pregnancy. 

Hydro- pyo- and hsematosalpinx, when matted by adhesions and 
surrounded by inflammatory exudation, may present a great resem- 
blance. But the absence of tenderness on pressure and the enlargement 
of the uterine cavity will assist greatly in forming a correct diagnosis. 
Cellulitic deposits are frequently to be distinguished only by the history 
of pain and fever, and their diminution under suitable treatment. From 
the projection of the tumour, when large, into one or other iliac fossa, 
where it is immovably fixed, it might at first be mistaken for a growth 
of the ilium. This mistake will, however, be rectified on pelvic exami- 
nation which Avill reveal its connection with the uterus. 

Large abdominal tumours are frequently associated with a marked 
uterine souffle, and may thus, from their shape and median position, 
resemble the pregnant uterus. But the absence of amenorrhoea, slow- 
ness of growth and harder consistence, with a coexisting want of mam- 
mary and other symptoms and signs of pregnancy, should prevent any 
serious misapprehension. 



58o SYSTEM OF GYNECOLOGY 

Erom ovarian growths fibroids are usually to be distinguished by 
their harder consistence ; although I have seen a unilocular parovarian 
cyst so tense that differentiation by this means Avas impossible. Other 
points of differential importance — such as uterine haemorrhage, 
uterine souffle, increased size of uterine cavity, and the nodular outline 
of the tumour — may, in individual cases, assist us in arriving at a cor- 
rect conclusion as to the nature of the growth; unfortunately those, 
one and all, are as frequently absent as present. When they have 
undergone secondary cystic change, the difficulty of diagnosis of fibroid 
from ovarian cystoma is still further increased, and in many cases 
laparotomy alone can decide the matter. 

Solid ovarian fibroma, from its rarity, may usually be set aside ; 
moreover, in the majority of cases, this is associated Avith ascites, a 
condition rarely met with in uterine fibroid. 

Subperitoneal tumours which grow downwards into the pelvis are 
fortunately rare, and probably arise in the majority of cases from the 
supravaginal cervix with the signs of which they closely correspond. 
They usually retain a broad attachment to the uterus, and from their 
position early give rise to severe and distressing pressure symptoms. 

As has already been shown, fibroids are extremely difficult to diagnose 
when small. When posterior they tend to lift the uterus upwards behind 
the pubic symphysis, and at the same time they fill up the recto-uterine 
and recto-vaginal space, where they may be felt as a hard fixed mass, 
bulging the posterior fornix and posterior vaginal wall. They may be 
closely simulated by incarcerated subperitoneal tumours ; but these are 
usually more or less movable on pressure, and present a distinct sulcus 
between the uterus and the growth. In most cases tumours which arise 
low in the uterus tend to shorten the intravaginal cervix ; by this prop- 
erty they can usually be diagnosed from the incarcerated fibroids of 
the upper part of the uterine body and fundus. 

Interstitial Fibromyoma. — The primary nodule in this variety always 
originates in the middle layers of the uterine muscle, but has no special 
tendency to grow or to be driven in any one direction. Thus when of 
any size, it equally bulges the mucosa inwards and the peritoneum out- 
wards ; or, in other words, it is surrounded on all sides with a layer of 
uterine muscle of equal thickness which forms the capsule; it may be 
practically considered, therefore, as a simple localised thickening of the 
uterine wall. 

These growths form a connecting link between the submucous and 
subperitoneal varieties, the characters of either of which they may 
secondarily assume, as already described. They produce the effects of 
both varieties on the size and position of the uterus ; simulating on the 
one hand the submucous, by causing enlargement of the uterine cavity, 
and at the same time, if of large size, displacing the organ after the manner 
of the subperitoneal. It will thus be seen that an absolute distinction 
between the described varieties is impossible, as the one drifts insensi- 
bly into the other. For clinical description, however, the classification is 



BENIGN GROWTHS OF THE UTERUS 581 

useful. The growth of the intramural variety is disposed to be more 
rapid, as its nourishment from the highly vascular capsule is less liable to 
be interfered with than in the other forms. From their freer circulation 
and more rapid growth they are usually more highly myomatous than the 
other varieties, and have thus a softer consistence. Hard fibrous nodules 
are also very commonly met with. 

Their direction of growth, though frequently abdominal, is prone to 
be intraligamentary and pelvic. They tend, therefore, soon to give rise 
to pressure symptoms. They may attain enormous dimensions in a com- 
paratively short time, and are particularly liable to secondary oedematous 
changes. From the multiple tendency of fibroids, examples of each 
variety may be simultaneously present in the same uterus ; each more 
or less masking the characteristics of the other. It is by no means 
uncommon to find a submucous polypus associated with both large peri- 
toneal and interstitial growths. It is in fact the exception for them to 
grow singly. 

Symptoms. — Being the connecting link between the subperitoneal and 
submucous forms, the symptoms of intramural growths are more or less 
a combination of those of both the former. Thus on the one hand, like 
the submucous, they frequently give rise to haemorrhage, dysmenorrhoea, 
leucorrhoea ; and at the same time they are associated with the marked 
pressure symptoms characteristic of the subserous. It must be mentioned, 
however, that haemorrhage, though a common symptom of this variety, 
is by no means invariably met with, even though the tumour be of large 
size and associated with great enlargement of the uterine cavity. 

Being always surrounded by a well-marked vascular capsule, from 
which the nutrition of all fibromyomas is derived, they naturally tend 
to grow with greater rapidity and to reach enormous dimensions. When 
large they are always associated with a marked uterine sou£B.e. When 
extremely small their symptoms and signs are practically identical with 
those of metritis and endometritis, namely, haemorrhage, with enlargement 
of the uterus and its cavity ; and from this it is impossible to distinguish 
them. When of considerable proportions the regular globular increase 
of the uterus can be made out without ditficulty. They may now be 
mistaken for submucous growths ; but usually the haemorrhage is not so 
severe, and the sound passes into the uterine cavity without difficulty. 
If any difficulty in diagnosis should remain, digital examination of the 
uterine cavity after cervical dilatation will at once decide the matter. 

When small the uterus, from increased weight, is low in the pelvis ; 
but when larger than a four months' pregnancy the uterus is pulled up, 
and the vagina is elongated. 

From the presence of a uterine souffle, and the frequently associated 
blue discoloration of the vulva, these tumours may at first sight be 
mistaken for pregnancy ; but this error should at all times be easily 
avoided by having regard to the menstrual history, the rate of growth, 
the softness of the vagina and of the tumour, and the absence of mammary 
changes. 



582 



SYSTEM OF GYNECOLOGY 



Fibromyoma of Cervix. — As has already been noted, cervical 
fibroids are much less frequent than those of the body and fundus uteri ; 
and though in this situation they are identical in their development and 
mode of growth with the latter, their clinical character is so distinct as 
to require separate description. 

As Duchemin has shown, an interstitial nodule of the uterine body 
may from a downward direction of growth become secondarily entirely 
cervical. At the same time, a tumour may by growth upwards and down- 
wards combine the characteristics of the cervical and corporeal varieties. 
I had a well-marked example of this class under my own care, where a 
tumour distinctly felt at the level of the umbilicus was protruded at the 
same time through the vulva. On account of its enormous dimensions 
removal by morcellation was performed, as it was expected that two 
growths might be present, — the one a large submucous polypus, and the 
other interstitial or subserous. After removal, however, of the vaginal 
portion, the anterior cervical lip was found tightly stretched over the 
tumour which formed one mass, involving the posterior cervical lip and 
the posterior wall of the uterine body. 





Fig. 149. — Submucous intravasinal cervical 
fibroid. (After Schroeder.) 



Fig. 150. — Subserous cervical fibroid, tilting 
uterus above pubes and bulging posterior 
vaginal wall. 



Cervical fibromyomas may be submucous, interstitial, or subserous. 

The submucous varieties may be stalked or sessile, and they usually 
project into the vagina. They are rarely bigger than the Qg^ of a goose, 
but they may be large enough to fill the whole true pelvis (Fig. 149). 
They tend to cause prolapsus uteri, and may closely simulate inversion 
of the fundus, the os uteri being frequently most difficult to find. 
They are rarely found to grow from the vaginal aspect of the free 
cervix. 

When subserous they necessarily arise from the supravaginal cervix, 
and burrow amongst the pelvic tissues in which they become immovably 



BENIGN GROWTHS OF THE UTERUS 583 

fixed ; thus they may give rise to grave and distressing pressure symptoms 
at an early stage. Tliey are most frequently met with posteriorly, and 
may burrow downwards between the vagina and rectum, so as to be felt on 
examination bulging the posterior vaginal wall (Fig. 150). In some cases 
Avhere the tumour is larger, the uterus is tilted high above the symphysis 
pubis, and the cervix may be quite out of the reach of the examining 
linger in the vagina. They also grow laterally between the layers of the 
broad ligament ; here they are usually sessile, though stalked examples 
have been described in this situation by Gemmel and Mallet. They 
rarely fill the utero-vesical septum, but when in this position they soon 
give rise to extremely distressing urinary trouble. 

Interstitial cervical fibroids are extremely rare. From their fixed 
position they completely obliterate the vaginal fornix, and so stretch and 
thin the opposing cervical lip that the os uteri is frequently only to be 
made out with the utmost difficulty as a narrow slit. The utero-vaginal 
relations are thus completely altered, and on examination the vaginal 
roof appears to be blocked by a hard resistant mass, with the free cervix 
absent and no apparent os uteri. They give rise early to pressure 
symptoms, especially if situated in the anterior cervical lip. 

When submucous they are generally associated with much leucorrhoea 
and feeling of pelvic weight; but, being free from the uterine cavity, 
they seldom give rise to the haemorrhages which characterise polypi of 
the uterine body. They may, however, cause severe dysmenorrhoea from 
obstruction to the menstrual flow. 

When small their diagnosis is self-evident ; but when large and filling 
the vagina their attachment is often impossible to trace, and they may 
thus be mistaken for a fundal fibroid with inversion, as a thorough bi- 
manual examination of the uterus and the use of the uterine sound are 
impossible. From their occasional broad attachment, involving the entire 
lip of the free cervix, they appear to rise directly from the vaginal wall, 
and have been mistaken for vaginal fibromyomas. 

Treatment. — When submucous and stalked, their removal is to be 
performed in the manner described for polypi. When sessile their 
enucleation is usually an easy matter. 

AVhen interstitial or subserous, however, their removal may be by no 
means simple, and is only to be attempted if they give rise to serious 
symptoms. In this position they are unusually slow in their growth, 
and I have seen several cases where they seemed to undergo no change, 
and remained innocuous during several years. 

If, however, symptoms indicate pressure, absolute removal only is 
of any value so far as my experience goes. Electricity and ergot are 
practically valueless. 

Extirpation of the growth by enucleation or morcellation per vaginam, 
as described p. 604, can be performed with much safety. 

Growth axd course of Fibromyoma. — The rate of growth of fibro- 
myomata is extremely variable. In many carefully observed instances 
they have been known to remain for years practically stationary ; while 



584 SYSTEM OF GYNECOLOGY 

in others large tumours have been known to develop within a few months. 
In general, however, their growth is comparatively slow. 

Their rate of increase is naturally proportionate to the means of 
nourishment ; and as this is entirely derived from the vessels of the cap- 
sule, it necessarily follows that thoroughly encapsulated tumours, such as 
the interstitial, tend to grow much more rapidly than those in which the 
capsule is partial or atrophied from pressure. In like manner tumours 
which are free from pressure develop more rapidly, which accounts for 
the usually large size and more rapid growth of the subserous and in- 
terstitial varieties as compared with the submucous. 

Sudden and rapid enlargement may occur ; but this is usually due to 
secondary changes such as oedema or haemorrhage into the substance of 
the tumour. Temporary enlargement due to increased vascularity is 
manifest during menstruation and pregnancy ; but it is probable that 
during the latter event a certain amount of increase remains, although, 
in many examples, involution and uterine contraction during the puer- 
perium cause actual diminution, as the result of retrograde changes. 

After the menopause active growth commonly ceases, and the tumours 
tend to atrophy, or at least to remain quiescent ; rapid enlargement may, 
however, occur after this period as the result of secondary metamorphosis. 

On account of the increased vascularity of the uterus due to the 
presence of tumours the menopause is usually delayed. Thus active 
growth may continue till the patient is well over fifty years of age, a 
point of great importance in prognosis. 

The actual changes which occur in the tumour after the climacteric 
is one of progressive induration, due to atrophy of the muscular ele- 
ments from diminished blood-supply. 

Secondary Changes. — These, as regards the size of the tumours, 
may be considered as either retrogressive or progressive. The former 
are represented by atrophy and degeneration — fatty or calcareous ; the 
latter by oedema, cystic formation, inflammation, and infiltration by 
embryonic cells. 

Atrophy. — This, the usual event after the menopause, may occur dur- 
ing the sexual period ; and may extend from a slight diminution in size 
to complete disappearance of the growth. The latter, though rare, has 
been noted by such close and competent observers that no doubt exists 
as to its actual occurrence. Thus Bantock relates an interesting example 
in the British Gynoecological Journal, and Schroeder (^5) has collected 
and observed a large number of cases. 

Slight diminution is, in the vast majority of cases, associated with 
evident hardening of the tumour, and is due to the excessive develop- 
ment of the fibrous tissue at the expense of the muscular; a process 
induced by diminution in the blood-supply, which may be due either to 
excessive pedunculation or to pressure. 

The process by which actual absorption is brought about is more difil- 
cult to determine. It is probable that, in some cases at least, oedematous 
infiltration may be the precursor of such a result ; as the softening of the 



BENIGN GROWTHS OF THE UTERUS 585 

tissue generally, the associated swelling and degeneration of the individ- 
ual cells, and the disappearance of their nuclei, point to a retrogressive 
change which may lead to complete obliteration. 

The probable factor in the production of the oedema is a contraction 
of the muscular wall of the uterus which, from compression of the tumour, 
interferes with the blood return. This probability is strongly supported 
by the fact that, in the majority of cases recorded, the absorption occurred 
after pregnancy or subsequent to treatment by electricity, ergot, or re- 
moval of the ovaries, all of which means are undoubtedly associated 
with much uterine contraction. Thoroughly encapsulated tumours are 
therefore more readily influenced in this manner. 

Further proof of the effect of excessive contraction of the puerperal 
uterus is to be found in the many cases cited where actual sloughing of 
the tumour has followed delivery. 

Calcification is due to the deposit of carbonate and phosphate of lime 
in the fibrous tissue of tumours which have ceased to grow, and gives 
rise to the so-called '• womb-stones." It is most frequently met with in 
the tumours of elderly women, in which after the menopause atrophy and 
induration have supervened. When present before the menopause, 
which is unusual, it is generally found in stalked subserous growths in 
which the means of nourishment are extremely slender. In elderly 
women, however, all varieties of fibromyoma are liable to this change. 

Calcification may be present in either of two forms, peripheral or in- 
terstitial. In the former and rarer variety, a thin rough chalky deposit 
is found on the surface of the growth only ; in the latter there is an 
infiltration of lime salts throughout the thickness of the growth, which 
may be localised in patches or invade its mass. So dense may this 
deposition be, that the surface of the cut sections can be polished like 
ivory. When peripheral calcification is complete, the centre of the 
tumour usually becomes necrotic from the complete arrest of its 
circulation. 

Many examples of the interstitial type have been described, but the 
submucous are but rarely met with ; one of the largest calcified tumours 
described weighed 2 lbs. of ozs.,^ and was found in a grave, within the 
pelvis of an apparently elderly woman. 

Thesecalcifiedtumours have been known anddescribed by Hippocrates 
and other ancient authors, since which time records of 51 published cases 
have been collected by Cruveilhier. According to some authors, the 
secondary change is an ossification, and the presence of true osteophytes 
has been recorded by Freund. In the majority of cases, however, it is 
mere calcification. 

Fatty degeneration is of extreme rarity. Examples, however, are 
described by Turner, and Hewitt {^^) ; and a specimen, described by 
Sir James Paget, is to be found in St. Bartholomew's Museum (Series 
33, :N"o. 74). 

Lardaceous degeneration is described in a unique case quoted by Stratz. 
1 Spec. 1799, Edinburgh Anat. Museum. 



586 SYSTEM OF GYNECOLOGY 

Colloid and myxomatous changes, on the other hand, are comparatively 
frequent ; but as they are intimately associated Avith the cystic changes 
later to be described, consideration of them may be deferred. 

Malignant degeneration and infiltration of fibromyoma is entirely con- 
fined to the connective tissue or sarcomatous type ; it is probable, indeed, 
that all encapsulated sarcomas are originally fibromyomas secondarily 
infiltrated. Carcinoma never occurs in fibroids. 

Spontaneous sloughing, or "necrobiosis," as it is termed by some au- 
thors, has been met with either partial or complete, and unassociated with 
septic influences or gangrene ; it is due to a sudden and complete arrest 
of the circulation through the tumour, resulting from a twisted pedicle 
or sustained compression. When due to the former, it is associated with 
symptoms of pain, fever, and peritonitis, similar to those occurring Avith 
a twisted pedicle in ovarian tumours. True gangrene, however, is much 
more frequent. This is particularly apt to occur in submucous growths 
which, after the complete arrest of their circulation by uterine contrac- 
tion or cervical constriction, become exposed to the influence of septic 
organisms entering by some ulceration or abrasion in the capsule. In 
this manner complete and rapid disorganisation of the tumour results; 
the growth may be slowly expelled. The expulsion is always associated 
with a vaginal discharge of an intensely foetid character. In many in- 
stances the termination is favourable to the patient, although, of course, 
death may ensue from general septic infection. Artificial attempts to 
bring about this natural process of cure by destruction of the capsule 
have been made, although generally with most disastrous consequences. 

Suppuration and abscess formation is the most frequent result of 
ulceration or destruction of the capsule, Avhether due to such interference 
as curettage, or the introduction of tents or other instruments for diag- 
nostic purposes, or to natural causes. It may, however, occur rarely in 
subperitoneal and interstitial tumours, where no external interferences 
can be ascertained. Examples of such have been recorded by Lee, 
Lisfranc, and Jonas ; and in a case of Bernays, treated by laparotomy, 
the enormous amount of six gallons of pus was evacuated from a sub- 
peritoneal growth. 

That true suppuration can occur without direct inoculation by organ- 
isms is perhaps contrary to the weight of present pathological teaching ; 
it is important, therefore, carefully to examine the pus in those obscure 
cases in order to ascertain the presence or absence of organisms. 

A number of cases have been recorded by Hall and others in which 
suppuration of fibroids occurred during the puerperium, the result, no 
doubt, of septic absorption from the placental site, or from bruises caused 
by labour. 

Ci/stic Changes in Fibromyoma. — Whether from a pathological or 
clinical aspect, the fibrocystic varieties of uterine tumours are most 
interesting. On the one hand their clinical course and physical signs are 
often so variable and ill-defined that they baffle detection, even at the 
hands of the most competent diagnostician ; while their development and 



BENIGN GROWTHS OF THE UTERUS 



5^7 



structure has been and indeed is still the theme of fruitful discussion 
amongst pathologists. 

Pathologically, they may generally be considered as due to secondary 
changes in previously existing fibromyomas, though at the same time it 
cannot be definitely asserted that they never arise de. novo. 






,^^^my^-->^ 



'v^ 



I- 




Fig. 151. — Advanced fibrocystic deg:eneration of stalked subperitoneal fibroid, -with partially twisted 
pedicle. From preparation. Half-size. Showing partial degeneration and ventricular appearance 
of cyst wall. 



Three ^veil-marked forms of secondary cystic development must be 
clearly distinguished : firstly, that due to simple degenerative changes 
only, which may be either fatty or the result of necrobiosis, as already 
described ; secondly, that due to a primary infiltration with secondary 
degeneration, which forms by far the most common and interesting 
group; and, thirdly, a rare variety due to the cavernous distension of 
the blood-vessels in the tumour. 



588 



SYSTEM OF GYNECOLOGY 



Though the detailed pathological appearances may have various minor 
differences in individual cases, the infiltrative varieties are characterised 
by a primary serous infiltration and associated myxomatous softening 
of the growth, accompanied by an oedematous swelling of the connective 
tissue, followed by more or less disintegration. When advanced, these 
changes result in the formation of spaces or false cysts filled with fluid, 
the walls of which are formed by the non-disintegrated portion of the 
tumour. At this stage the muscular bundles, being still present, prevent 
the formation of large cavities, and give to the cyst wall a peculiar uneven 
appearance, closely simulating the cardiac cavities with their columna3 
carnese. Subsequently, however, the muscle also becomes disintegrated 
and large spaces are formed (Fig. 151). The contained fluid in the large 




Fig. 152. — Edematous interstitial cystic fibromyoma. Drawn from preparation. 
U, Uterus enlarged to 7 inches in cavity ; C, cyst in tumour. 



One-third size. 



cysts varies from a pale amber to a dark porter colour, the change in 
colour being due to the extravasation of blood. In most instances the 
fluid on evacuation spontaneously coagulates ; this is due to its highly 
albuminous nature, the exuded serum being highly charged with the 
products of tissue disintegration. Chemical and microscopic examination 
show it to contain serum-albumin and fibrin, with more or less mucin, 
blood, and detritus from degenerated tissue. In the early stages the 
fluid is almost entirely composed of serum -albumin. 

The degenerative process may be confined to definite portions of the 
tumour, with intervening areas of higher grades of tissue ; but in some 
instances the disintegration is so complete that a unilocular cavity is 
formed, bounded only by the pre-existing capsule of the tumour (Kieux). 

In the early stages the cut surf ace may have a checkered appearance, 
some portions having the characters of an ordinary fibromyoma, others 
showing softened areas of apparently myomatous tissue, while dotted here 



BENIGN GROWTHS OF THE UTERUS 



589 



and there may be seen small cysts, varying in size from a pinhead to a 
grape. In other instances the entire growth is uniformly softened, and 
from its surface there exudes on section a clear yellowish fluid, which 
from its escape causes a marked diminution in the size of the tumour. 
In this stage these growths are described as oedematous fibroids. In a 
somewhat more advanced stage a number of cavities filled with fluid 
will be seen scattered throughout (Fig. 152). The entire growth may 
Avith great ease be enucleated from its surrounding capsule. 

Microscopically, in the early stages, the structure is seen to be fibro- 
muscular : the intermuscular fibrous and connective tissue is swollen and 
myxomatous, while the intercellular spaces are distended with fluid. 
Leopold and Fehling, and Ehein have described an endothelial lining 
forming the walls of the dilated intercellular spaces, which they recognised 
as lymph channels, and accordingly designated the tumour cysto-lym- 
phangiectodes ; but in cases described by Gusserow (26) and Spiegelberg 
no such lining was apparent. Out of five well-marked examples which I 
have carefully examined, in only one have I found evidence of spaces 
lined with endothelium, and 
in this one but a few small 
patches scattered through- 
out a large tumour (7 lbs.) 
(Fig. 153). 

Examination of the cyst 
wall of advanced cases failed 
to show any true lining. In 
two cases of very rapidly 
growing interstitial tumours 
of this type, the microscope 
showed a large number of 
round and spindle-shaped 
cells situated between the 
bands of muscle fibres, while 
throughout the entire mass 
were isolated large round 
cells of an endothelial char- 
acter. In all the cases ex- 
amined blood extravasations were found scattered through the growth. 

From the appearances presented there is but little doubt that in these 
tumours we have to deal with a serous infiltration or chronic oedema of 
pre-existing fibromyoma, which results either in a simple degeneration 
of a myxomatous nature, with disintegration and cyst formation, or is 
associated with active connective tissue cell proliferation. 

The latter, from its appearance, seems to border on malignancy ; and 
it is probable that some such tumours may actually become myxo- 
sarcomatous ; but in the majority of cases they are unlikely to give rise 
to secondary metastases, -and they do not tend to recur after removal. It 
is almost certain that the cause of both varieties is the same, namely, 




Fig. 153. — Microphotograph of cedematous fibroid, showing 
endothelial lined spaces, x 180. 



590 SYSTEM OF GYNECOLOGY 

interference with the venous return — a condition by no means difficult 
to account for when one considers the usual sluggish circulation of 
fibroids generally : this view is corroborated by the constant appear- 
ance of areas of blood extravasation throughout the oedematous tissue. 
The process must then be regarded as one of chronic oedema. 

That this obstruction is more complete in some cases than others, 
accounts for the colour presented by the growth, which varies from a light 
pink to a deep purple. In the latter case one seldom fails to find throm- 
bosed vessels scattered throughout it. The immediate cause of impairment 
in the circulation is most frequently to be found in the capsule ; thus 
interstitial tumours are by far the most frequently affected. The tumour 
may grow rapidly without sufficient dilatability of its surrounding capsule, 
or be compressed by the active contraction of the thick muscular sur- 
roundings. In these cases the entire tumour is affected uniformly. It 
may also be met with in stalked subserous tumours as the result of 
blockage to the circulation in the pedicle. This is beautifully demon- 
strated, in the preparation from which Fig. 9 was drawn, as the result 
of a partial twist of the pedicle ; in these cases the change may be par- 
tial only, and is usually more acute, large cysts being rapidly formed 
and extensive haemorrhages usually occurring. In submucous polypi 
oedema is of course extremely common, but their expulsion is usually 
completed before large cysts are developed ; or, from subsequent com- 
plete arrest of the circulation, sloughing and gangrene occur. 

From a clinical aspect fibrocystic tumours are extremely interesting. 
In the early stages they have a soft, boggy consistence which is apt to 
be mistaken for fluctuation. In the later stages, when large cavities 
are present, fluctuation may be made out ; though from the thickness 
of their walls this is by no means definite, even when the cavities are 
of considerable size. 

Large cysts are specially likely to occur in pedunculated subserous 
growths ; indeed, in fifty cases collected by Heer, five only were inter- 
stitial and two submucous. Coussat describes a fibrocyst of the cer- 
vix. Cullingworth (13) describes a similar condition in which the 
tumour weighed over 6 lb., and developed rapidly after the menopause. 

On the other hand, in interstitial tumours simple oedematous change 
without the formation of large cavities vastly preponderates. As I have 
already pointed out, this change is almost always met with in solitary 
tumours ; although in one case I observed small secondary nodules in the 
uterine wall. Their growth is more rapid than that of simple fibroids, 
but usually slower than that of a glandular ovarian cystoma ; though 
there are many exceptions to this rule. They may attain an enormous 
size, examples of 80 lbs. weight having been recorded. From the occa- 
sional rupture of large vessels in their interior also they may rapidly 
assume large proportions. In a case cited by Routh several such rupt- 
ures were said to be distinctly felt by the patient. Sudden and definite 
enlargement from haemorrhage, common in these tumours, may be also 
met with in ovarian cysts. 



BENIGN GROWTHS OF THE UTERUS 591 

Cystic degeneration may occur at any age, and the subsequent growth, 
of the tumour seems to be uninfluenced by the ovaries. Thus cystic and 
cedematous tumours may first give indications of their presence after the 
climacteric ; moreover, they are in no way influenced by removal of the 
uterine appendages : these are material points of difference when com- 
pared with simple fibromyoma. 

According to their locality, like simple fibromyoma, they may or 
may not be associated with uterine haemorrhage ; but, as they are most 
frequently interstitial or subserous, this symptom is seldom prominent. 

The diagnosis is at all times difficult, and particularly so in the stalked 
subserous form where the signs may be identical with those of a cystic 
ovarian tumour. The symptoms, as we have seen, are by no means 
characteristic. Although special attention has been directed by Eouth 
and Tait to the general absence of uterine haemorrhage, this, however, 
is doubtless due to their rarity as submucous tumour. 

When interstitial, their soft consistence and rapidity of growth, the 
usual absence of uterine haemorrhage, and the associated enlargement of 
the uterine cavity must at all times be considered suspicious ; while if 
developed after the menopause, and causing painless enlargement of the 
uterus without haemorrhage, the diagnosis is almost assured. In like 
manner when a large, soft, regular uterine growth is found developing 
in a patient under thirty years of age, with or without haemorrhage, the 
presence of a so-called " oedematous fibroid " is strongly probable. 

Aspiration has been recommended in order to ascertain the special 
characteristics of the fluid as regards coagulability, and so forth. Such a 
procedure, however, cannot be too severely condemned : firstly, in the 
early stages no fluid can be withdrawn ; secondly, so extremely feeble is 
their vitality that a fatal issue may be caused from resulting gangrene of 
the tumour ; and lastly, as removal is the only treatment, whether for this 
condition or for any tumour with which it can be mistaken, exploratory 
tapping must at best be unnecessary. It may further be stated that 
spontaneous coagulability is by no means a specific character although it 
occurs in the majority of cases. A uterine souffle is evident in all cases 
of the interstitial kind ; but in the one case of stalked subserous fibro- 
cystic I have seen it was entirely absent, and thus could not be dis- 
tinguished from an ovarian cystoma. 

Another variety of cystic degeneration, the ^^ cavernous angioma," 
though pathologically well known, is extremely rare in practice. It is 
characterised by the abnormal development and dilatation of the blood- 
vessels of the growth, a change which may involve the whole tumour, 
or be localised in patches. Virchow (69) first drew attention to its 
occurrence and named the condition "Myoma telangiectodes." On 
section the tumour appears as a spongy mass containing a large number 
of cavities, which vary in size from that of a pinhead to a pea, and 
contain soft reddish thrombi. Subsequently, from rupture of these small 
cysts, with resulting coalescence, larger cavities are formed with irregular 
walls which closely resemble the interior of the cardiac ventricles. 



592 SYSTEM OF GYNECOLOGY 

Microscopically the characteristic feature is the innumerable cavities 
filled with blood, and lined by endothelium ; these are separated from each 
other by intervening fibrous and muscular tissue, in which run many 
capillaries. Examples have been recorded by Cruveilhier, Lee, Weber, 
Leopold and others. In many instances they are clinically to be 
recognised by their increase at the menstrual periods, and their subse- 
quent diminution. 

Two examples of primary origin of these tumours in the uterus have 
been recorded by Klob (35) and Boldt. 

Though but few angiomatous tumours have been met with and 
described, it is probable that this kind of secondary change may form 
the origin of a considerable number of fibrocystic myomas; as it is well- 
known that angiomatous growths are particularly liable to undergo a 
secondary cystic transformation, further, the appearances presented 
by cystic angioma in other situations closely simulate those met with in 
a number of fibrocystic growths of the uterus. 

This variety of cystic change may also be associated with an appar- 
ently sarcomatous infiltration of the growth proper, an example of 
which is described by Aslanian. 

A close connection exists between this variety of tumour and the 
ordinary infiltrative type of cystic degeneration ; for though in the early 
stages they may appear widely dissimilar, in the later stages of large cyst 
formation and degeneration their appearances must be almost identical ; 
moreover, actual cases of combined lymphangiectoid and telangiectoid 
growths have been described by Mtlller. 

It will thus be obvious how intricate is the pathology of fibrocystic 
uterine tumours, and how tumours, which in their origin appear widely 
different, may subsequently assume identical features. It is probable 
that their rarity to a great extent accounts for the indefiniteness of our 
knowledge of their development. 

Pregnancy and Fibromyoma. — As already stated, there can be little 
doubt that uterine fibroids as a class tend materially .to prevent 
pregnancy, and are a direct cause of sterility both relative and absolute ; 
equally certain is it that their position in the uterine wall prevents this 
function to a greater or less extent as the tumour approaches the uterine 
mucosa. For this reason the submucous type is most closely identified 
with sterility ; as then the extreme vascularity of the mucosa forms an 
unfavourable seat of implantation for the impregnated ovum, and one 
from which it tends to become separated by haemorrhage. Sterility is 
less likely to occur with small subserous and interstitial tumours, though 
distinctly to be traced in some cases ; in many cases it is due to the 
habitual occurrence of abortion, which is probably induced in part by 
the difficulty of uterine dilatation, in part by the tendency to haemor- 
rhage from increased vascularity. 

In a case of large interstitial fibroid of the anterior uterine wall, 
which came under my own observation, the dilatation of the uterus was 
so interfered with, that the cavity was distended in the form of an 



BENIGN GROWTHS OF THE UTERUS 593 

-m. 

hour-glass ; the placenta was situated in the upper compartment, and 
the foetus grew (till the 18th week) in the lower. After abortion it 
was found impossible to remove the placenta, as the communication 
between the two cavities was not large enough to admit the finger; 
death occurred from septicsemia. The uterus and tumour weighed 9 
lbs. A similar case is described by Lusk. 

Should gestation proceed to full term, parturition may or may not be 
interfered with. The effect naturally varies with the position of the 
growth : when low in the uterus, or subserous and incarcerated in the 
pelvis, it may form an insuperable barrier to the birth of the child ; when 
higher in the uterine wall they frequently cause uterine atony and 
irregular contractions, with their accompaniments of delay and hsemor- 
rhage. Submucous pedunculated tumours frequently present in front 
of the child. 

Prom the unequal dilatation of the uterine cavity malpresentations 
of the foetus are common. Lefour found that of 100 pregnancies thus 
complicated 49 per cent were preternatural in their presentation. 
Winckel estimates breech presentations to be eight times more common, 
and transverse to be increased thirty-five-fold. Moreover there is a 
decided tendency to prolapse of the cord; and undoubtedly placenta 
prsevia is more frequently met with. 

Although, frequently, pregnancy and parturition are in no way 
affected by the presence of fibroids, it must be acknowledged that their 
association increases the risks both to mother and child in proportion 
to the size and position of the growth. Susserot, in 147 cases of 
pregnancy, shows a mortality of 55 per cent, while Pozzi asserts that in 
interstitial fibroids of large size the mortality is as high as 53 per cent. 
Although such statistics by no means represent the general mortality 
from pregnancy associated with fibroids, they are of value in demonstrat- 
ing the possible gravity of their presence. 

Of great interest also is the effect of pregnancy on the fibroids 
themselves. With its occurrence the tumour in most instances rapidly 
increases in size, the enlargement being due to hypertrophy of the 
individual muscular fibres of the tumour, and to a serous infiltration of 
the intercellular tissue, from increased vascularity. The consistence of 
the growth is thus much changed, and from its softness its true nature 
may be mistaken. 

After parturition, an involution of the muscular elements of the 
tumour occurs simultaneously with that of the uterus itself ; and this may 
be so marked that positive diminution or even total disappearance of the 
tumour may occur. This happy result is probably attained by firm 
uterine contraction impairing the blood-supply to the growth, and caus- 
ing a degeneration of the muscle fibres analogous to that which occurs 
in normal puerperal involution. 

Such a favourable termination is unfortunately by no means the rule ; 
indeed, from my own observations, a permanent enlargement of the 
tumour is the more common consequence. In some cases this is more 

2q 



594 • SYSTEM OF GYNECOLOGY 

evident than in others, and is due to the extrusion of the growth from the 
uterine wall, by contraction of the organ ; but in many instances I have 
carefully noted a permanent increase after pregnancy, a result which 
probably accounts for the frequency of subsequent sterility (see p. 563). 
Puerperal uterine contractions often cause expulsion of submucous 
growths ; this I have seen twice within two months of the confinement, the 
expulsion in each case being associated with alarming haemorrhage. Sub- 
mucous tumours are also liable, from the contraction of the uterus cutting 
off their blood-supply, to become gangrenous, and hence to be a source 
of septic infection. This result may also occur in subserous tumours. 
From the serous infiltration present during pregnancy the tumour may 
continue to grow rapidly after delivery, from increased connective tissue 
proliferation and other secondary changes. 

True suppuration may be met with in subserous tumours as a result 
of parturition; this has been shown by Speigelberg to be due to the 
passage of organisms from the uterus through the lymph spaces. These 
tumours may also slough from bruising during labour, and may thus 
give rise to fatal peritonitis. 

Gangrene and sloughing of a submucous polypus is described by 
Charrier to have occurred during pregnancy; the patient recovered, 
though birth of the foetus took place before the removal of the septic 
mass. 

Submucous polypi have frequently been described as presenting in 
front of the foetus during labour, and in several instances have been 
mistaken for the foetal head and delivered by forceps (21). 

The diagnosis of pregnancy imth jibromyoma is usually simple, though 
at times great difficulty may be experienced. 

The presence of amenorrhoea, coincidently with an excessive enlarge- 
ment of the uterus and attached tumour, is at all times suspicious and 
almost characteristic. Occasionally, however, menstruation may continue 
for some months in spite of gestation, and here by palpation alone can 
the true condition be ascertained. 

Large interstitial tumours when associated with pregnancy may, from 
the regular contour of the rapidly enlarging tumour, closely simulate a 
hydatidiniform degeneration of the chorion (9) or a rapidly growing 
cystic myxo-sarcoma. 

In like manner an intraligamentary growth may resemble an extra- 
uterine gestation so closely, that absolute certainty of diagnosis is im- 
possible. Simpson describes such a case (58). If, however, in these cases 
the uterus itself be definable from the intraligamentary growth, its size 
will be of great value in distinguishing it from an extra-uterine gestation ; 
as in the latter the uterus, though enlarged, never corresponds with the 
size of a normal intra-uterine pregnancy. 

From the difficulties which may be due to the tumour masking the 
signs of pregnancy, it is well in all cases of rapidly growing fibroids to 
remember the possibility of its concurrence, as by this caution many 
serious and even fatal errors may be avoided. 



BENIGN GROWTHS OF THE UTERUS 595 

The treatment to he adopted ivhere pregnancy is complicated by jibro- 
myoma must vary according to the existing conditions in each, individ- 
ual case. Unless urgent symptoms demand active measures interference 
is uncalled for. 

When the growths are small, pregnancy is but seldom affected by 
their presence ; and even large tumours may but slightly interfere with 
its normal completion. The methods by which nature may overcome 
difficulties apparently insuperable is certainly surprising. Many cases 
are on record of primarily incarcerated growths which have grown up- 
wards into the abdomen after gestation was far advanced ; indeed, this 
may take place even during labour, as the result of retraction. 

When from pressure or other causes interference is demanded, the 
position and character of the growth must necessarily define the method 
of treatment. When low in the uterus and remaining pelvic, it may give 
rise to symptoms of gravid retroversion ; or, as in a case of my own, such 
symptoms may be induced by a large tumour of the anterior wall causing 
the gravid uterus itself to be retroposed and incarcerated. Iq these 
cases, even if pressure symptoms be absent which they seldom are, 
attempts at reposition are demanded, as the tumour must form an unsur- 
mountable barrier to delivery. 

If no symptoms of pressure be present, though incarceration exist 
in spite of attempts at reposition, it is well to allow pregnancy to pro- 
ceed without interference, as the tumour in the later months, or even 
during labour, may be drawn out of the pelvis and in no way interfere 
with delivery. Should it still, however, remain fixed, and thus entirely 
block the passage of the child, laparotomy is the only resource. The 
choice of operation to be adopted must vary with the situation; but 
complete hysterectomy would certainly appear to be preferable to either 
simple Csesarean section or Porro's operation. The mortality from 
Csesarean section is stated by Sanger to be 83-7 per cent. The induction 
of abortion when the tumour is placed low in the uterus is rendered 
difficult and dangerous by the want of dilatability of the lower uterine 
segment and cervix, which may render it impossible to introduce the 
finger for removal of the secundines. Should the tumour be intra- 
vaginal, its removal can at any time be performed without inducing 
labour. 

Large abdominal fibroids with pregnancy, which give rise to urgent 
symptoms, may be treated either by induction of labour or abdominal 
section. The former operation, on account of its minor severity, has 
been strongly advocated by a large number of writers, but has been 
equally strongly condemned by others, who base their arguments partly 
on the high mortality after even spontaneous abortion — which has been 
stated by Lefour to be about 35 per cent — and partly on the fact that 
the growth remains untreated. 

The treatment by laparotomy at the hands of Schroeder (56) and 
others has been doubtless most satisfactory, but at the same time it 
shows the enormous fatality in all of about 48 per cent. 



59^ SYSTEM OF GYNAECOLOGY 

The details of the operation necessarily vary with the position and 
size of the tumour. If pedunculated, the tumour may be removed by 
myomectomy, and the pregnancy continue ; a successful result is thus 
frequently obtained. If sessile or interstitial, the site or size of the 
growth must govern the method of operation, yet even in these cases 
myomectomy has been performed without interfering with the progress 
of gestation, as shown by Leopold (41). He further states that in 
thirty-one cases of myomectomy during pregnancy for pedunculated or 
sessile tumours seven mothers died, twenty-one were operated on between 
the fourth and sixth month, and seventeen carried to full time. 

The Porro-Csesarean operation, or the entire removal of the uterus, 
are the methods chiefly followed. A successful case of the latter has 
been described by Jessett. Ordinary Csesarean section, on account of 
its excessive mortality already cited, should not be performed, not even 
in the few cases which may seem suitable for its adoption. 

In general, therefore, the magnitude of these operations and their far 
from uniform success, would incline us to the less heroic measure of the 
induction of abortion, if urgent symptoms should arise from large abdo- 
minal fibroids complicating pregnancy. But each individual case must 
be treated on its own merits, the urgency of the symptoms in some cases 
absolutely demanding immediate surgical interference. When, however, 
symptoms are not so urgent as to require such energetic measures, 
personal experience has shown that abortion may be induced with most 
happy results, and the future treatment of the tumour can be under- 
taken with decidedly less risk at a subsequent period. 

Treatment of fibromyoma may be divided into Medical, Electrical, 
and Surgical. 

The medical treatment is chiefly symptomatic, although the entire dis- 
appearance of growths has been attributed in some instances to its means. 
Many drugs have been recommended — such as mercury, iodides, and 
liq. calcis chloridi — which have been supposed to exert a direct absorp- 
tive effect on the tumour, and probably not without some reason. 
Sodium chloride mineral waters have an undoubted effect in this direc- 
tion. Since the rapid advancement of surgery in gynaecology, however, 
such uncertain methods have practically ceased to command attention, 
and treatment by drugs is now almost entirely confined to purely symp- 
tomatic uses. 

As in the majority of cases haemorrhage is the urgent symptom, and 
as it is one which more readily lends itself to medicinal antidotes, it is 
needless to say that the drugs used to control it are many. Sulphuric and 
gallic acids, turpentine, cannabis indica, and many others, have had their 
day ; but there is none which has in any way approached the value of 
ergot of rye which, so far as present medical treatment is concerned, 
holds the held. Many writers strongly urge that by its use the develop- 
ment of the tumour is prevented, and its size actually reduced. There can 
be but little doubt that such a result is occasionally met with ; although 
usually not until after many months or even years of active and regular 



BENIGN GROWTHS OF THE UTERUS 597 

employment. The action of ergot appears to be twofold: firstly, by 
causing contractions of the uterus, it tends to expel the tumour from its 
wall, and at the same time retards its circulation by direct pressure ; 
secondly, by its well-known direct contractile action on the blood-vessels, 
it materially interferes with the nutrition of the growth. Though ergot 
seems but seldom to exert a curative effect upon the growth and develop- 
ment of the tumour, it is of great value in reducing the large amount of 
haemorrhage associated with many of them, and as a uterine haemostatic 
it has had, and still occupies a high position ; though the more decided 
results derived from the scientific use of the galvanic current are now 
rapidly superseding this form of treatmient. As directed by Hildebrandt, 
who first introduced it, ergot is best employed by hypodermic injection; 
and for this purpose the solution recommended by Prof. A. R. Simpson is 
very suitable, namely, I^ Ergotine 3ij., Chloral hyd. 3iv., Aq. dist. 3vj. 
Twelve drops of the above contain 3 grs. of ergotine, which is an ordinary 
dose. The chloral is merely added as a preservative. Care must be 
taken to inject the solution deeply into some fleshy part, such as the 
buttock, so as to avoid abscess formation. The injections are to be 
made twice weekly as a rule, but every second day during the menstrual 
period ; in this manner its use must be continued for months if any 
change in the growth is to be anticipated. The patient may be taught to 
inject herself. The drug may be given by the mouth, or by suppository ; 
but it seems thus to have a less decided effect. 

Of late the fluid extract of hydrastis canadensis, in 20 to 30 minim 
doses, has been employed as a uterine haemostatic in bleeding fibroids, 
and its use has met with much favour. From the difficulty in procuring 
the drug in a fresh state, however, treatment by this means has been 
too limited to form reliable results. 

Electrical Treatment. — The treatment of fibromyoma by electricity, 
though by no means a new method, had not been undertaken in a 
thoroughly scientific manner until comparatively recent years. Routh in 
his interesting and able work (54) speaks of it in 1853 as a comparatively 
new method, and describes a case in which he got a most favourable 
result by passing daily through the tumour a current of high intensity 
for two hours at a sitting. This proceeding was discontinued after about 
fifteen applications, as the patient suffered from ulceration of the parts 
at the sites of the electrodes, which were placed on the back and cervix 
respectively. 

After that time it was used only in an occasional and haphazard 
fashion until Apostoli in 1886 again called attention to its value, and 
brought the subject forward on a more exact and scientific basis ; 
Apostoli's method evoked much interest, and was the source of endless 
discussion of a most animated and even bitter kind. ]S"ow, however, 
that these useless polemics have abated, and the treatment can be seen 
in an unprejudiced light, its high value becomes apparent. 

Apostoli's method is fully described in the article on the ^'Electrical 
Treatment of Diseases of Women. " 



598 SYSTEM OF GYNECOLOGY 

The action of the current thus administered is said to be twofold — 
local and interpolar. 

Be this as it may — chemical, vaso-motor, or otherwise — there is no 
gainsaying the large array of successful cases cited by Apostoli, Keith, 
Milne Murray, and many others, where the current acted beneficially, 
— first as a haemostatic, secondly, by arresting the growth of the tumour, 
and, thirdly, in many instances actually causing permanent diminution in 
the size of the tumour. With ordinary care the treatment can be carried 
out without risk and with little inconvenience. 

As a haemostatic it will seldom be found to fail if the tumour be 
smaller than a six months' pregnancy. Larger tumours, however, do not 
seem to be so rapidly benefited, although they are by no means beyond 
the scope of beneficial influence. 

Pressure symptoms, as a rule, are relieved greatly and promptly, while 
the feeling of "well-being" evinced by the patient is frequently rapidly 
developed, and forms one of the most satisfactory benefits of the 
treatment. It has been averred that the symptoms of pressure, of 
haemorrhage, etc., are merely temporarily benefited, and recur as soon as 
the use of the electricity ceases. That they do return in some cases is 
true, as in some cases removal of the appendages fails to stop menstrua- 
tion ; but in the great majority of instances a permanent arrest of 
bleeding and a diminution in the size of the tumour is the result. Out 
of twenty-five cases in which I arrested excessive haemorrhage more than 
two years ago, in only four has it returned, and then was stopped again 
by similar methods (30). 

The arrest in development and permanent diminution in the size of 
the tumour is equally striking. Apostoli computes it to occur in 95 
per cent of cases. In submucous tumours the tonic uterine contractions 
induced by the current tend in many instances to cause them rapidly to 
become pedunculated, and further to expel them as polypi. This I have 
noticed in eight of my last fifty cases. 

From its great success this method of electricity should, as a 
conservative method of treatment, be tried in all cases before the larger 
and more dangerous operations are attempted. Should it fail (as 
undoubtedly it sometimes does) the chances of successful operation, so 
far as my experience shows, are in no way diminished, though the 
contrary is averred by some surgical opponents of the method. 

When from incarceration of the tumour in the pelvis, or from 
any other causes, it may be found impossible to introduce the intra- 
uterine electrode, it becomes necessary to puncture the tumour through 
the vaginal wall. 

It is probable that after puncture adhesions will be set up, and thus 
complicate subsequent operation: this result should always be remem- 
bered, before this method of treatment is adopted, as it forms a slight 
foundation upon which antagonists of the electrical treatment of fibroids 
generally are but too eager to build their arguments. 

Fortunately the cases where puncture is necessary are rare, as in the 



BENIGN GROWTHS OF THE UTERUS 599 

majority of instances the cervix is freely accessible to the introduction 
of the sound. 

Surgical Treatment. — This may be either symptomatic or radical, 
vaginal or abdominal. 

The symptomatic vaginal methods of treatment are naturally directed 
against the two urgent conditions of pressure and haemorrhage. 

Treatment of Pressure Symptoms. — The feeling of down-bearing, and 
the accompanying vesical symptoms, so frequently complained of as due 
to the simple increased weight of the uterus, may be much benefited by 
the introduction of an accurately fitting ring pessary. 

The extremely distressing pressure symptoms of fibroids located in 
the true pelvis may, if the growth be subserous and incarcerated, be 
generally removed by elevating the tumour above the brim of the pelvis, 
and maintaining it in this position by a simple Hodge or ring pessary. 
This is, of course, applicable only to freely movable growths such as 
pedunculated subserous tumours in the fundus of a retroverted or flexed 
uterus. When arising from the supravaginal cervix or lower part of 
the uterine body such manipulation is impossible, the tumour being 
absolutely fixed in the pelvis. 

The elevation of the tumour is most easily performed with the 
patient in the Sims' or genu-pectoral position ; steady upward pressure 
by the fingers is to be made through the vagina, or rectum, in a manner 
similar to that recommended for the reposition of a gravid retroflexion 
of the uterus. Should any difficulty be met with the patient should be 
ansesthetised, as thus, by the relaxation of parts, resistance is frequently 
diminished in a surprising manner. 

Treatment of Hcemorrliage. — The mechanical methods for the arrest of 
haemorrhage are manifold, and perhaps the most simple is intra-uterine 
injection or swabbing. The substances which have been used for this 
purpose include almost all known styptics ; but that which seems to 
have given the most satisfactory results is undoubtedly iodine. Dr. 
Savage was the first to recommend this drug, and he preferred the 
injection of 1 or 2 drachms of the strong undiluted Edinburgh tincture. 
He was careful, however, to observe that, before injection, dilatation of 
the uterus must be obtained which, by allowing of the free egress of 
the injected fluid, prevents the intense pain and occasional subsequent 
attacks of peritonitis previously met with after this method of treatment. 
Swabbing the interior of the uterus with a dressed uterine sound, pre- 
viously dipped in the tincture of iodine, is to be preferred to the intra- 
uterine injections; it is more easily performed, and is equally efficacious. 

In preference to the use of the strong tincture, I have used with al- 
most unfailing success a weak solution of the same tincture (3ij- to 5 xvj. of 
water), and, with a Fritsch or Bozeman's catheter introduced to the fundus 
uteri, allowed the whole quantity slowly to pass through the uterus. 
This should be performed about the second or third day of the period, 
and so far experience has shown that it can be thoroughly relied upon. 
Previous dilatation is seldom necessary to allow of the introduction of 



6oo SYSTEM OF GYNAECOLOGY 

the catheter, as during the menstrual period marked softening of the 
cervix and even dilatation of the os are usually met with. 

Intra-uterine douching with hot water is a most valuable method of 
rapidly arresting uterine haemorrhage. The water should be used at a 
heat exceeding 110° F., as below this temperature it only aggravates the 
condition. Simple vaginal syringing with water at the same tempera- 
ture frequently has an immediate haemostatic effect, by causing strong 
uterine contraction ; but this cannot be depended upon. This action of 
hot water has been shown by Dr. Murray to be due to the contractile 
effect upon unstriped muscle ; thus the uterus itself, and the walls of 
the blood-vessels, are thrown into a prolonged tonic spasm without subse- 
quent reaction. 

Plugging. — This may be either vaginal or uterine, and is demanded 
when the haemorrhage is so severe as to threaten life. Intra-uterine 
plugging by means of tupelo tents is the best method, as not only is direct 
pressure thus frequently brought to bear on the actual bleeding surface, 
but the resultin,'? dilatation may assist in a marked degree in arresting 
subsequent bleeding ; after removal of the tents, also, direct intra-uterine 
exploration can be made, and any subsequent operation performed which 
may seem advisable. Emmet recommends plugging the uterus with a 
tampon of cotton soaked in a solution of alum ; this he introduces into 
the uterus in the form of a strip, an end being left hanging from the 
cervix for subsequent removal, should the uterus fail to expel it by in- 
duced contraction (19). 

Dilatation of the cervix, either by bougies and tents or by free incis- 
ion, has been long known in some cases to have a marked effect in 
stopping the haemorrhage from fibroids ; and at one time it was a very 
generally adopted method of treatment. It is very useful in relieving 
the dysmenorrhoea so often met with in submucous tumours. The haemo- 
static action is ascribed by Simpson, Nelaton, and others as due to dilata- 
tion allowing the uterus to retract and contract firmly upon the contained 
tumour, and thus by compression of the vessels to prevent haemorrhage. 

Incision of the capsule of the tumour, although followed immediately 
by a temporary excess of bleeding, subsequently diminishes the haemor- 
rhage to a great extent. This action is probably due to the relief of 
tension in the capsule, which permits of the retraction of the lacerated 
sinuses from whence the bleeding arises, and at the same time mitigates 
the congestion which is present. Not only has incision a haemostatic 
effect, but it has been recommended as a curative method, in order that, 
as the circulation of the tumour is impaired by the destruction of the 
capsule, the growth may undergo retrograde changes, and slough ; as in 
some cases of polypus in which from pressure or other causes the nutrition 
is likewise interfered with. This method of treatment cannot, however, 
be too strongly condemned ; as fatal results commonly occur, in conse- 
quence of the absorption of septic organisms from the gangrenous tumour. 

Curettage of the uterine cavity is a procedure much practised by 
many gynaecologists. In cases of the small interstitial growths, which 



BENIGN GROWTHS OF THE UTERUS 60 1 

do not change the regular shape of the uterine canal, the operation may 
be practised with much temporary benefit as regards the menorrhagia; 
but in the vast majority of cases, which are projecting submucous 
growths, the use of the curette is of but little value, from the impossi- 
bility of removing the entire mucosa, and specially that portion of it 
which actually covers the growth, and which is the most fertile source 
of the haemorrhage. At the same time the operation is by no means 
devoid of risk ; as occasionally, from severe laceration and destruction 
of the capsule, subsequent death and gangrene of the tumour follow. 
In one case I have seen fatal consequences from this method of treat- 
ment, due to septicaemia from gangrene of the tumour. 

Removal of the Uterine Appendages. — As a curative method of treat- 
ment for the bleeding from uterine myoma, this operation was first per- 
formed by Lawson Tait in 1872 ; since that time increased experience 
has proved it to be one of the greatest advances in gynaecological surgery. 
About the same time Battey of Georgia performed the operation of re- 
moval of the ovaries for dysmenorrho^a ; but to Tait must the credit be 
given of associating the operation with the cure of fibroid tumours. The 
actual operation also differs materially in the fact that Tait, Avhile remov- 
ing the ovaries, at the same time removes as much as possible of the 
Fallopian tube ; by this means, he avers, the beneficial effect of the 
operation is much increased, through the consequent destruction of 
the nervous supply to the endometrium, which is chiefly centred in a 
large nerve trunk which enters the uterus just underneath the angle of 
attachment of the Fallopian tube. 

The statistics of Tait are indeed striking, and those of other eminent 
operators are worth perusal. Thus, Tait shows that of the first 272 
cases in which he had operated in this manner for uterine fibromyoma, 
twelve succumbed from the operation ; a mortality of 44 per cent. He 
further records, that of fifty cases followed for six years after the opera- 
tion, in seventeen the tumour had entirely disappeared ; and in fourteen 
had become so diminished as to be harmless : forty-one of the fifty were 
in perfect health. From what has been stated, it will be seen that the 
operation not only has the effect of arresting the haemorrhage and the 
growth of the tumour, but in the majority of cases it actually causes 
diminution in its size ; in many instances, indeed, total atrophy and 
disappearance of the growth have been noted. 

Cases of failure are to be accounted for in two ways : firstly, inability 
or neglect to remove the entire Fallopian tube with its surrounding 
nerves ; and, secondly, the nature of the growth. From the size of the 
tumour, or from the direction of its growth, the layers of the broad 
ligament may become so split that removal of the entire appendages 
is impossible ; the operation is then valueless, both as regards the arrest 
of haemorrhage and increase in size; to this, probably, the majority of 
failures in arresting menorrhagia is to be credited. 

It would appear that in the majority of cases the growth of oedema- 
tous tumours is not arrested. 



6o2 SYSTEM OF GYNECOLOGY 

In cases of prominent submucous tumours the haemorrhage is fre- 
quently aggravated after the operation ; but expulsion of the tumour 
within a few months may follow. Should haemorrhage continue, there- 
fore, after an apparently complete operation, the cavity of the uterus 
should be carefully explored again by the finger, so that this source of 
trouble, if present, may at once be removed. 

From the low mortality and, as statistics further show, the excellent 
results accruing from its adoption, this operation cannot be too highly 
commended in a certain proportion of cases. The discrimination of 
suitable cases for its performance cannot be fixed by definite rules, and 
this must be determined by the medical attendant. On the one hand, it 
is not to be hastily adopted before less severe measures have been tried ; 
and on the other, we must avoid the equally blameworthy procedure of 
temporising till the favourable opportunity has passed. 

In general, it may be said that the operation is indicated in cases of 
bleeding and growing fibroids, where the electrical or other treatment has 
been tried without success ; or as an alternative to the electrical treat- 
ment, should the patient so decide after having had the advantages and 
disadvantages of both fully explained. 

The wholesale removal of uterine appendages for fibroids, without 
any previous attempts at treatment, cannot in the majority of cases be 
too strongly condemned, and must be considered not only unscientific, 
but culpable. From the ease with which the operation can be performed, 
its very satisfactory results, and the exaggerated credit accruing to the 
operator ; the tendency has been rampant, and unfortunately still exists, 
to follow this line of treatment in all cases of fibroid ; the majority of 
which are amenable to treatment by methods attended with less risk 
and with no mutilation. Removal of the appendages should never be 
undertaken, for small fibroids, without previous dilation and exploration 
of the uterine cavity, as small submucous polypi may be the sole cause 
of the bleeding, which is readily cured by their removal. 

Operations for Removal of the Tumour. — (1) Eemoval of pedunculated 
fibroids. The methods by which these growths are to be removed vary 
with the situation and extent of the pedicle. If completely intra-uterine, 
all attempts at removal must, of course, be preceded by dilatation of the 
cervix. Should no previous dilatation of the cervix exist, this is to be 
obtained by means of tents or Hegar's dilators ; but in the majority of 
cases, where the intravaginal cervix and .os uteri externum alone are 
undilated, free bilateral incision by scissors up to the reflexion of the 
vaginal roof, is by far the most simple and efficacious method. 

The ease with which the polypus itself can be removed varies accord- 
ing to the character and extent of the pedicle. Should it be composed but 
of a layer of mucous membrane — as met with in the " free " variety (see 
p. 576) — simple torsion of the growth is usually sufficient ; but should 
the pedicle be thick and composed of uterine muscle (encapsulated vari- 
ety), torsion must be aided by cutting. This may be done in the follow- 
ing manner. The patient is placed in the dorsal position, and the tumour 



BENIGN GROWTHS OF THE UTERUS 603 

exposed by means of specula and vaginal retractors ; tlie growth, is then 
seized by strong-toothed forceps and slowly rotated ; with blunt-pointed 
curved scissors the pedicle is next snipped gradually through, rotation of 
the tumour being continued as far as possible during the whole time of 
cutting — a process by which much haemorrhage is frequently avoided. 

Excessive traction on the tumour is to be avoided, as partial inversion 
of the uterus may occur. Indeed the inverted portion of the uterus 
has been mistaken for the pedicle, and accordingly snipped through. 
In all cases, therefore, the fundus uteri must be carefully examined 
bimanually, so that any depression of inversion may be recognised. 

Eemoval of polypi by means of the serre-noeud, chain ecraseur, and 
galvano-caustic wire, are still favourite methods of operation, and are to 
be recommended as safe and efficacious ; but as they have no advantages 
over the simple cutting method described, are infinitely more tedious, and 
involve a large increase in the already large armamentarium of the gynae- 
cologist, they are rapidly becoming less and less frequently practised. 
The haemorrhage, after removal of polypi by torsion and incision, is 
usually but slight; but if troublesome is readily arrested by hot water 
injection, and intra-uterine plugging. 

In cases of vaginal polypi, where from the large dimensions of the 
growth access to the pedicle is impossible, reduction in the size of the 
tumour must be gained by the removal of portions, piecemeal, until 
the pedicle is reached. In some of these cases incision of the tumour 
is followed by a considerable loss of blood ; but this can usually be pre- 
vented by strong traction and torsion of the growth, aided if necessary 
by a running loop of strong cord passed round its base. After the 
pedicle becomes accessible, traction must be suspended and the pedicle 
snipped by means of simple torsion and scissors, as already described. 
After removal, the uterine cavity should be thoroughly washed out with 
an antiseptic, and lightly packed for twenty-four hours with sterilised 
Berlin wool impregnated with iodoform. The packing is of much value 
in rapidly curing the endometritis which so frequently is associated with 
these growths. 

Removal of Sessile Tumours. — Simple Incision of the Capsule. — This 
method is now fortunately almost obsolete. Its advocates contend that by 
its adoption removal of the tumour results from two causes : first, from 
the arrest of nutrition of the tumour by interference with its capsular 
circulation ; and, secondly, by the promotion of expulsion of the growth 
from its capsular surrounding by uterine contraction. By this means it 
is also averred that the natural destruction and expulsion, occasionally 
met with, are closely followed. Greenhalgh for this purpose incised 
the capsule with the thermo-cautery ; Baker-Brown, after free incision 
of the capsule, lacerated the growth itself, and left it to slough. Other 
methods of hastening the destruction of the tumour after capsular in- 
cision, such as the injection of perchloride of iron, etc., have also been 
recommended. 

It may be said at once, however, that such crude and unscientific 



604 SYSTEM OF GYNECOLOGY 

methods should never be permitted. They may simulate a natural 
process, but it is one which under all circumstances is fraught with much 
danger, and frequently ends fatally, while, further, it cannot but be 
apparent that the conditions are in the two cases essentially different. 
In nature's action we have to deal with a growth which is practically 
cut off from the circulation, lymphatic and other ; while in the artificial 
method we are suddenly setting up suppuration in a growth freely com- 
municating with the surrounding tissues, and from which absorption is 
but too ready to take place. It will thus be seen that if dangerous 
under natural conditions it will be greatly intensified under artificial 
conditions. 

The other vaginal methods of surgical interference adopted for the 
removal of sessile tumours are: — 

Simple enucleation, ligature of uterine arteries, simple morcellation 
of tumour, simple vaginal hysterectomy, vaginal hysterectomy by mor- 
cellation. The full details of these operations will be found in other 
sections of this work devoted to surgical methods. 

Removal of sessile submucous growth per vaginam by enucleation was 
recommended by Velpeau, Atlee, Amussat, and others, more than fifty 
years ago ; but, from its high mortality, it rapidly fell into disrepute. 
The procedure has, however, within the last few years been renewed with 
great enthusiasm, and, fortunately, on improved methods and v/ith a know- 
ledge of antiseptics, has been practised with most satisfactory results. 

To Emmet is probably due the credit of the revival of the method as, 
by dogged perseverance throughout the last thirty years, he has by his 
traction method secured results which at once elevate the operation to 
a position worthy of adoption. Undoubtedly in his operation is to be 
found the rudiments of " morcellation " which has been adopted by Pean 
for the removal of all varieties of fibromyoma, and with whose name it 
is almost entirely identified. 

From the simple removal of the tumour Pean has passed to the more 
formidable operation of vaginal hysterectomy, by which means he removes 
all tumours less than a six months' pregnancy, and this with the truly 
astounding statistics of but four deaths in two hundred cases (21). In 
these methods he has been worthily followed by E-ichelot and De Ott, 
whose combined statistics show 143 cases with one death. 

With such a magnificent array of successes, one must admit that the 
operation is a decided advance in gynaecological surgery, and heartily 
congratulate the operators on their handiwork. But, unfortunately, 
there is no gainsaying the fact that this success has stimulated a surgical 
fashion in this direction which has passed far beyond the limits of dis- 
cretion, and cannot be too strongly denounced. 

In no country has the operation fever become more acute than in 
America ; and when one reads the astounding assertion, that all fibroids 
should be operated on by complete hysterectomy as soon as discovered (1), 
and this published by an operator who has done twenty such operations 
within a year, it is surely time that a bold front should be opposed to 



BENIGN GROWTHS OF THE UTERUS 605 

such, merciless mutilation. Like almost every operation in surgery, the 
operation has its legitimate place, and when required should be performed ; 
but cases needing such measures form but a small minority of fibromyo- 
mas, certainly not more than 10 per cent. Simple recovery from the 
operation may reach 97 per cent, but in many cases protracted invalid- 
ism results. Only as a last resort is it warranted ; the less energetic 
measures of electricity and removal of the appendages, in the majority 
of cases, are amply sufficient. 

The ahdomincd surgical methods of removing fibroids, namely, myo- 
mectomy and hysterectomy, are fully discussed in another portion of the 
System. They, like the vaginal methods just mentioned, admirably fill 
a limited function in the treatment of these tumours, w^hich is not only 
justifiable but necessary. Such measures are particularly needed in 
cases of growing abdominal tumours larger than. a six months' pregnant 
uterus, where the appendages cannot be removed entirely ; and also in 
the rapidly growing oedematous cystic grow^ths, where removal of the 
appendages is useless and therefore unnecessary, and for w^hich total 
removal is alone of avail. 

B. Tumours of the Mucous Lining. — The simple mucous growths 
of the uterus, from their tendency to become stalked and to protrude 
through the os externum into the vagina, are generally known as 
" mucous polypi " ; but under this name are included new growths of 
widely different character. The name is also unhappy in so far as it is 
taken to represent the structure rather than the situation of the neoplasm. 
Growing, as these polypi do, from the mucosa, they are the result of a 
proliferation of the glandular or connective tissue elements alone or com- 
loined; and include therefore adenomas, fibro-adenomas, and fibromas. 

The simple adenoma is usually met with in the cervix, and appears 
as a red, soft, smooth growth, varying in size from a pea to a walnut. On 
section it shows a sponge-like structure due to the dilated glands, which 
are separated from one another by thin trabeculse of connective tissue. 
The gland cavities, visible to the naked eye, are filled with mucus ; and, 
microscopically, they may be seen to be lined with epithelium, varying 
from cubical to elongated cylindrical forms. The tumour is covered by 
epithelium which may be either cubical or stratified squamous. The 
latter form I have found covering polypi w^hich sprung from at least a 
quarter of an inch wdthin the canal of the cervix, and protruded into the 
vagina (30). The same thing has also been demonstrated by Underhill 
and Ackermann. In its simplest variety, w^hich Semon has described as. 
a papillary outgrowth from the vaginal aspect of the cervix, this form 
of epithelial covering is naturally more frequently met wdth. 

In its most simple form this variety of grow^th is represented by a- 
simple mucous gland which, on closure, has become distended with mucus 
(Nabothian follicle); and subsequently so protruded from the surface 
that it has become pedunculated. By the combination of a series of 
such cysts, w4th proliferation of the glandular mucosa, the more com- 
plex sponge-like growth is formed. 



6o6 SYSTEM OF GYNECOLOGY 

Usually, with, the glandular proliferation, there is a corresponding 
development of interglandular connective tissue : this is generally of an 
extremely cellular character, and wanting in the fibrous elements. The 
growth in this instance has a somewhat firmer consistence, and is usually 
rough on its surface, so that it resembles a ripe strawberry. These 
growths may be sessile, forming protuberances within a dilated cervix ; 
and it is probable that in many cases they owe their origin to cystic ex- 
tension of the new glands in the so-called " erosion " of the cervix, so 
frequently met with in cervical inflammation. 

In the same manner an inward growth of the new glandular structure 
into the cervical tissues with subsequent distension of the glands may 
arise, which is well known as " follicular hypertrophy of the cervix." 

Localised glandular proliferation of the mucosa in the body of the 
uterus, comparable to that described in the cervix, and giving rise to 
distinct polypoidal intra-uterine growths, has been described by Gusserow 
(27), Scliroeder (57), Duncan (18), and others, and has been designated 
"adenoma polyposa." It must, however, be considered as of rare 
occurrence. 

A more common variety of intra-uterine growth is the fibro-adenoma, 
which may be looked upon, primarily, as a localised hypertrophy of the 
normal mucous membrane. Usually in these cases the fibrous tissue pre- 
dominates, the glands tending to increase rather in size than in number, 
and thus to form canals which permeate the growth in all directions ; 
this variety of growth, as described by Underbill and others, has been 
called " channelled polypus." In some instances these growths are also 
found growing from the cervix. They may grow to a large size ; in one 
example described by myself the growth weighed 21 ounces (37). When 
small and multiple the same condition has unfortunately been described, 
by Olshausen, under the name of '^ endometritis f ungosa polyposa " — 
a name at once misleading and scientifically incorrect. 

These neoplasms would appear from their structure to owe their 
origin to an active hypertrophy of the fibrous tissue of a portion of the 
mucosa. The glands situated in this area, however, do not themselves 
actually proliferate, but become enormously elongated from the outward 
growth of their surrounding fibrous stroma. The seat of active growth 
is seen by the microscope to be in the periphery of the tumour, im- 
mediately beneath the epithelium. There the tissue is embryonic and 
cellular, while towards the centre it is fibrous and well formed. 

By dilatation of the glands, and obstruction to the escape of their 
secretion, cysts may be formed. In these instances the growth corre- 
sponds exactly with the common fibrocystic tumours of the mamma 
which, among many other names, have been called "fibroma intra- 
canulaire " and " cystosarcoma fibrosum." Like the mammary tumours, 
they are essentially benign ; though in a certain percentage of cases they 
recur. The extremely embryonic and cellular character of the periphery 
of these growths might certainly lead one at first sight to classify them as 
sarcoma ; but from this they materially differ in that the cells do not 



BENIGN GROWTHS OF THE UTERUS 607 

maintain their embryonic character, but rapidly develop into mature 
connective tissue. Moreover, they are never associated with metastases, 
or infiltration of the surrounding lymphatics ; and it would appear that 
when recurrence occurs, it is due not to a local malignancy but to 
hypertrophy of another portion of the mucosa. 

The embryonic blood-vessels in the actively growing cellular periph- 
ery, being ill supported by the surrounding stroma, are readily ruptured ; 
.such is probably the origin of the violent bleedings which form so char- 
acteristic a clinical feature of these growths. 

Another more uncommon variety of simple polypus found growing 
from the uterine mucosa is the fibrous papilloma. This is a purely fibrous 
tumour of a papillary form, covered by a single layer of epithelium. 
From the primary growth secondary offshoots are developed, each carrying 
with it an epithelial covering of cubical cells ; thus the gross appearance of 
the tumour shows a rough, irregular surface of cauliflower-like character. 
From the approximation of these papillae, the interspaces closely resemble 
glands permeating the substance of the growth and opening on its surface ; 
but on microscopic examination their true structure is at once revealed. 
In a case described by Kindfleisch, small cavities lined with epithelium 
were found in the substance of the polypus, which he ascribed to the 
coalescence of the papillae at their apices. The tissue of the tumour 
proper is entirely fibrous, with cells in all stages of development ; the 
centre is composed of well-formed fibres, while towards the periphery (as 
in fibro-adenoma) the fibres are more and more embryonic : thus the cen- 
trifugal development of the neoplasm is demonstrated. These tumours are 
frequently described as " cauliflower papilloma " ; but as this name is more 
commonly applied to malignant epithelioma of like appearance, it leads 
to confusion and should be dropped. Apart altogether from the nomen- 
clature, they have been reckoned as closely allied to epithelioma, but 
microscopic examination and clinical observation at once disprove such an 
affinit}'-. Isolated cases, as those quoted by AYagner, may occur in which 
a simple fibrous papilloma may subsequently develop into a malignant 
epithelioma, by proliferation of its epithelial elements. Such an event, 
however, can only be a coincidence. Such a transformation is far more 
likely to occur in the adenomatous types, where large numbers of 
epithelial cells are in active proliferation ; it is probable that in many 
instances this variety of growth may be the origin of it, and more 
especially the papillary type described by Semon (already mentioned), 
which is covered by many layers of squamous cells. 

From what has been shown of their structure, it will be evident that 
all mucous polypi result from the increased growth of one or other of 
the normal tissues of the mucosa, namely, from the glandular and con- 
nective tissues. They will, therefore, present an indefinite number of 
varieties of structure, entirely dependent upon the comparative excess of 
each ; and they are to be classed accordingly. At the hands of some 
authors they receive but little attention, and even by others are dismissed 
as mere local inflammatory excrescences. Doubtless such a classification 



6o8 SYSTEM OF GYNECOLOGY 

may be simple and convenient, but as a scientific description it cannot be 
too strongly condemned. If consistently adopted, uterine fibromyoma 
must be looked upon as localised metritis, and ovarian fibromyoma as 
a kind of ovaritis. It is surely strange that the mucous growths of the 
uterus should be thus summarily dealt with, while similar conditions of 
the mamma, nose, and intestines are described as definite and inde- 
pendent neoplasms. 

Symptoms. — The ever present symptoms which direct the attention of . 
patient and physician to mucous polypi are leucorrhoea and haemorrhage. 
The former is perhaps the more characteristic, and sometimes occurs in 
almost incredible quantities, associated with much irritation and pruritus 
vulvae. Its character varies : generally it is clear, watery, and odourless ; 
but it may be muco-purulent. There is but little tendency to that necrosis 
of the tissues of the tumour which gives the characteristic foetid char- 
acter to malignant papillomas. Hsemorrhage also is often profuse, and 
is by no means confined to the menstrual periods, metrorrhagia being 
particularly frequent. 

The source of bleeding is not far to seek when it is remembered 
how feebly supported are the numerous embryonic blood-vessels in the 
periphery of the tumour. At the same time the menorrhagia is probably 
increased by the irritation set up by the tumour. 

Unlike fibromyoma they may occur at all ages ; and this feature 
forms perhaps the most interesting practical point in their consideration. 
Occurring, as they often do, late in life, many years after the menopause, 
they give rise to the alarming symptom of post-climacteric bleeding, and 
form the large majority of the few cases in which this symptom is not 
due to malignant disease. We have seen that they may occur on any 
portion of the uterine mucosa, but they are most frequently met with in 
the cervical canal. Their size is usually less than that of a walnut, and 
they may assume most varied shapes. In most instances they are smooth 
and soft, though in the papillary type the contrary is the case. As has 
already been shown, they have a marked tendency to recur after re- 
moval ; but on this account alone they cannot be called malignant. 

When palpable their diagnosis is as a rule easy, although the deter- 
mination of simple papillary growth from papillary epithelioma can 
never be made with certainty without microscopic examination. 

When completely intra-uterine their presence is frequently not 
suspected, and patients may be treated for long periods for leucorrhoea 
and uterine haemorrhage, with slight uterine enlargement, till finally on 
dilatation of the cervix their presence is disclosed. Severe leucorrhoea 
and uterine haemorrhage always indicate an early digital exploration of 
the uterine cavity. 

Intra-uterine polypi, and particularly the variety called " endometritis 
f ungosa," may, from their tendency to cause post-climacteric haemorrhage, 
be difficult to distinguish from intra-uterine cancer ; a decision can be made 
by the microscope alone, when the absence of active typical epithelial 
proliferation in the glands will be noted. Malignant disease of the 



BENIGN GROWTHS OF THE UTERUS 609 

uterine body is commonly associated with, pain, whicli is seldom present 
with, mucous polypi, unless of large size. 

Although in their recurrence after removal they still more closely 
simulate malignant disease, they never give rise to secondary metastases, 
nor are associated with marked cachexia. 

Treatment. — This is generally to be summed up in the word removal. 
When small, pedunculated, and projecting through the cervix, this can 
easily be done by torsion or evulsion, with subsequent cauterisation of 
the site by Pacquelin's cautery. This latter procedure is useful, not 
only in arresting the haemorrhage, which may be extremely severe, but 
also in so destroying the base that recurrence is prevented. 

When large, their removal is most easily effected by scissors, as in 
the case of submucous polypi (see p. 602). The stump should, however, 
if possible, be thoroughly cauterised in all cases. 

Intra-uterine polypi necessarily require primary cervical dilatation. 

As these neoplasms have been known to be the forerunners of 
malignant disease, and also in some instances to recur locally, a chance 
is giv^en to those smitten with the hysterectomy furor to remove the 
uterus. Unless actual signs of malignancy exist such a procedure is 
wholly unwarrantable. 

I have more than once been called upon to remove successive growths 
of this kind from the same patient, and I can recall two well-marked 
cases. Five years ago, for the fourth time in eighteen months, I re- 
moved from a patient aged fifty -nine, still alive and healthy, a large 
number of intra-uterine adenomas, which had given rise to severe 
uterine haemorrhage, and which from the microscope alone I knew to 
be of simple nature. 

In the other case, a young woman of twenty-three, I removed, for 
the last time, seven years ago, and three times within two years, a 
simple adenoma of the cervix ; since then she has had perfect health, 
has married, and borne four children. After removal of intra-uterine 
adenomas, cauterisation of the interior of the uterus is most thoroughly 
and easily performed by means of fuming nitric acid, followed immedi- 
ately by thorough intra-uterine irrigation. 

Another variety of uterine polypus, but not strictly a new growth, is 
the uterine haematoma or fibrinous polypus. From its almost constant 
relationship to the puerperium it is commonly known as a " placental 
polypus," and is due to the deposition of blood-clot in successive layers 
upon a retained portion of uterine decidua or placenta. The blood 
tumour, thus formed in a stalactitic manner, subsequently becomes or- 
ganised, and may remain attached to the uterine wall for months. Dur- 
ing the time of its formation there is a constant haemorrhagic discharge, 
and usually at the period of its expulsion severe and copious bleeding. 
Though rarely non-puerperal, in one case, fully described in Ed. Obstet. 
Transactions, 1893, I met with a typical example in a non-puerperal 
patient, who suffered from intra-uterine fibro-adenoma ; the case, so far 
as I can learn, is unique. The roughened surface of the tumour acts, 

2r 



6io SYSTEM OF GYNECOLOGY 



doubtless, like retained portions of secundines, by causing blood coagu- 
lation. The polypus weighed 8 ozs. 

F. W. N. Haultain. 



REFERENCES 

1. Am. J. of Obsfet. June 1895, p. 652.-2. Apostoli. Trans. French Surgical 
Congress, 1889. — 3. Aslanian. Archiv. de Tocol. et gynaec. Feb. 1895. — 4. Bayle, 
Diction. Paris, vol. vii. p. 73.-5. Bernays. Am. J. Ohstet. 1895, p. 357.-6. Boldt. 
Am. J. Ohstet. 1888, p. 834.-7. Brown, Baker. Ohstet. Trans. Lond. vol. i. p. 329.— 
8. Cabot. Bost. Med. J. June 1887. — 9. Champneys. Practitioner, January 1896. — 10. 
Charrier. Gazette des Hop. 1864. — 11. Cohnheim. Vorles. v. Algemeine Pathol, p. 
641. — 12. CoussAT. Bullet. del' Acad. Belgique, 1S62. — 13. Cullingworth. iond. Ohstet. 
June 1876. — 14:. Ibid. Ohstet. Trans. London, VSQQ. — 15.Dannion. Electro-therapeutics, 
March 1888. — 16. Duchemin. Thesis sur tumeur fibroides de I'uterus, 1863. — 17. 
Duncan. Sterility in Woman, p. 12. — 18. Ibid. Ohstet. Trans. Lond. 1893. — 19. 
Emmet. Diseases of Women, p. 572.-20. Ibid. Practice of Gynaecology. — 21. 
Fergusson. Lond. Ohstet. Trans, vol. i. — 22. Garceau. Am. J. of Ohstet . Msirch 
1895, p. 336. — 23. Gemmel. Archiv de Tocologie, vol. i. p. 700. — 24. Greenhalgh. 
3Ied. Chir. Trans, vol. lix. p. 41. — 25. Gurlt, Von. Langenbeck's Arch. yoLslxy. — 
26. Gusserow. Neubild. d. Uterus, p. 203. — 27. Ibid. Archiv f. Gyndk. vol. i. p. 
246.-28. Guyon. Tumeur fibreuse de I'uterus. — 29. Haultain. Fd. Ohstet. Trans. 
vol. xix. —30. Ibid. vol. xviii. p. 160. — 31. Hertz. Virchow's Archiv, vol. xlvi. p. 
235. — 32. Hunter. Am. J. Ohstet. vol. xxi. p. 62. — 33. Jesset. Brit. Gynsec. J. 
1895. — 34. Keith. Ed. Ohstet. Trans. Yol.xn. — '6^. Klebs. Handbuch d. Path. Anat. 
1876. — 36. Klob. Wiener med. Wochenschrift, 1863. — 37. Ibid. Path. Anat. der 
Weibliche Sex. organ, p. 173. — 38. Langenbeck, Von. Aj^chiv f. Gyndk. vol. xxv. 

— 39. Lee. Med. Chir. Trans. Lond. vol. xxxiii. p. 281. — 40. Lefour. Les fibromes 
d' uterus au point de vue de G7'0s.sesse. — 41. Leopold and Fehling. Archiv f. Gyn. 
vol. vii. p. 531. — 42. Lisfranc. Cliniq. med. de la hopit. de la Pitie. Paris, 1843. 

— 43. M'Clintock. Clin. Mem. on Diseases of Women, 1863, p. 97. — 44. Marey. 
Trans. Internat. Med. Cong. 1887, vol. ii. p. 836. — 45. Mattel Annal. de Gynaecol. 
vol. vi. — 46. MiJLLER. Archiv f. Gyndk. 1889, p. 249. — 47. Murray, Milne. Ed. 
Ohstet. Trans, vol. xv. —48. Olshausen. Arch.f. Gyndk. vol. viii. p. 97.-49. Porak. 
Annal. Gyndk. vol. xxvii. p. 140.-50. Pozzi. Sydenham ed. p. 422. — 51. Rhein. 
Archiv f. Gyn. vol. ix. p. 414.-52. Rindfleisch. Path. Gewehslehre, 1869, p. 63. — 53. 
RiEux. Bullet. Soc. Anat. vol. xxiv. p. 19. — 54. Routh. Fibrous Tumours of Womb, 
1864, p. 26.-55. Schroeder. Lehrbuch, p. 230. — 56. Ibid. Zeitschr. f. Geburt. und 
Gyndk. — 57. Ibid. vol. i. p. 89. — 58. Simpson. Ohstet. Works, ^.155. — 59. Spiegel- 
berg. Archiv f. Gyn. vol. vi. p. 345. — 60. Stratz. Zeitsch.f. Geburt. u. Gyndk. vol 
xvii. — 61. SussEROT. Inaug. Dissert. Rostock, 1870.-62. Ibid. 1880.-63. Tait 
Diseases of Women, ^p. 194. — 64. Thorburn. Diseases of Women, p. 259. — 65. Tinns 
Trans. Ohstet. Soc. London, vol. ii. — 66. Turner. Edin. Med. Jour. 1864. —67. Under 
HILL. Ed. Ohstet. Trans, vol. v. — 68. Virchow. Archiv, vol. iii. — 69. Ibid. Gesch 
wulstlehre, iii. p. 195. — 70. Wagner. Gehdrmutter Krehs, p. 13. — 71. Wyder, Arch 
f. Gyndkol. vol. viii. 

F. W. N. H. 



H YSTERECTOMY 6i i 



HYSTERECTOMY 

Hysterectomy is a term which, should have been restricted to the com- 
plete cutting out of the womb ; unfortunately, however, it was in common 
use before the complete extirpation of the uterus had become a recognised 
operation, so we can only accept things as they are, and under this 
common term include a number of very dissimilar operatious. Thus we 
have this term hysterectomy applied quite correctly to the procedure of 
complete extirpation of the uterus, either for cancer, sarcoma, or fibro- 
myoma, and equally correctly, whether the operation be performed 
through the abdomen, through the vagina, or by a combination of those 
methods ; we distinguish these several methods as abdominal, vaginal, 
or ab domino-vaginal hysterectomy respectively. 

But the term hysterectomy has been long applied to a class of opera- 
tions, in which the uterus, at any rate in the majority of cases, has been 
only partially removed, and in many merely cut into, the depth of the 
cutting in varying from the complete removal of a portion of its wall 
throughout its thickness to a mere incision through the peritoneal coat. 
These procedures would have been better classed under the name 
myomectomy, or hystero-myomectomy. 

Since the operations for uterine tumours were established on a firm 
footing, and recognised in surgery, it has become the usual practice when 
removing fibromyomas to take away the whole upper part or body of 
the uterus, merely leaving the cervix, whether the operation ended as an 
intraperitoneal or extraperitoneal procedure : these operations have been 
very generally described by the term supravaginal hysterectomy, which 
distinguished them from the complete extirpations previously referred to. 
Now it is becoming increasingly common in the intraperitoneal operations 
to remove the whole organ, including the cervix ; so that with so many 
very different operations it is impossible, except by prefix and by the 
addition of explanatory terms, to cover all with one name: thus we 
speak of vaginal hysterectomy for cancer, and so on. Before proceeding 
to describe these various operations, it is necessary very briefly to refer 
to the diseases and conditions which render them advisable or necessary ; 
I say advisable or necessary, because there is no class of operations in 
which the question of expediency, as distinguished from necessity, so 
often arises. 

Tumours of the uterus are dealt with in a separate article, so that of 
these I shall only say enough here to make my meaning clear. Fibro- 
myoma, or fibroid growth, is by far the most common disease leading 
to the question of operation; then come cancer, in its varying forms, 
and the very much more rare sarcoma. 

Then there is another very distinct class of cases in which irreducible 



6i2 SYSTEM OF GYNECOLOGY 

inversion, or complete procidentia, may raise the question of the propriety 
of hysterectomy. The operation in these cases is always vaginal. 

Certain malformations of the pelvis, which render natural child-birth 
impossible, may also give rise to the question of the propriety of remov- 
ing some part, or the w^hole, of the internal sexual organs. 

Fihromyoma uteri is classified, according to its situation in the 
uterine wall, as subperitoneal, mural or intramural, and submucous. 
These terms sufficiently explain themselves ; they each have attached 
to them certain definite symptoms, and these I will briefly describe. 

Subperitoneal growths are generally multiple, often so numerous as to 
form a complete coating to the whole uterus, hard and glistening on 
section, commonly round or oval in shape, covered with a thin and usu- 
ally easily separable layer of peritoneum, and having their chief blood 
supply from vessels coursing over and among them, rather than in them. 
They often attain a very great size, and this, and the irritation they set 
up in the peritoneum — an irritation sometimes leading to malignant 
disease — are the two conditions which may make it desirable to extirpate 
them. Often they hardly affect the size or shape of the uterine cavity 
at all, but sometimes they elongate, twist, or deform it, and they may 
then cause an increase of menstrual loss. 

Intramural growths often appear to be solitary ; one greatly exceed- 
ing in size any others which may be present. They usually contain 
more muscular fibre and less fibrous tissue, and are more vascular; 
they are also multiple, but rarely to the same extent as in the previous 
variety : in some cases almost the whole uterine wall is so involved in 
one of these growths that it appears to be an infiltration, but on careful 
examination of such a specimen it will be seen that the process is a 
pushing aside and a thinning of the true uterine wall, and that a sort of 
capsule separates the growth from the wall : these growths also attain 
a great size, and much more often than the subperitoneal growths lead 
to increased menstrual flow, or to irregular uterine haemorrhage. 

Submucous growths do not differ essentially from the subperitoneal ; 
they are generally multiple, they commonly cause haemorrhage, and they 
often greatly enlarge and distort the uterine cavity : they frequently 
become gradually separated from the muscular tissue of the uterine wall, 
except at one spot where their blood-vessels enter, and thus assume a 
polypoid form : in this state they are extruded from the uterine cavity, 
and appear in the vagina; sometimes they slough from the pressure 
exercised upon their bases and blood-vessels by the contracting uterus, 
when a very dangerous condition arises. 

All three varieties may involve the cervical portion of the uterus, 
though obviously the subperitoneal can only do so ^Dartially, and by 
extension from the body ; their presence in the cervix is often, however, 
of great surgical importance in deciding whether an operation be feasible 
at all ; and, if so, what its exact nature shall be. All three varieties may 
be found in the same individual, but more often one kind predominates, 



HYSTERECTOMY 613 

or is present alone. The subperitoneal and intramural most often attract 
attention by their size ; and both, in their early stages, are apt to cause a 
good deal of pain, especially at the menstrual periods : the intramural 
and submucous forms most commonly first make their presence felt by 
the increased flow, irregular losses, and pelvic discomforts or actual pain. 

Conditions justifying Operation. — Great and rapid increase of size, 
repeated and serious haemorrhage, and severe pain were thought at one 
time to be the only justifications for operation. Now, however, the in- 
creasing success of the operations in competent hands, and the generally 
improved conditions of abdominal surgery, encourage the surgeon to 
advise operations of expediency when necessity can hardly be urged. 
Thus a patient may be in excellent health, and yet greatly object to go 
through life carrying a great tumour in her abdomen. When the con- 
ditions are favourable for safe removal, such a patient, in my opinion, is 
quite justified in seeking relief by operation ; and the surgeon, if he has 
had sufiicient experience in such cases, is quite justified in operating. I 
do not think that a surgeon without special experience is justified in per- 
forming these operations ; the patient is nearly always well enough to go 
to a special operator, and the inexperienced cannot appeal to emergency 
as a plea for interference. In some cases in which size, haemorrhage, 
or pain make an o];)eration urgently necessary, it may be impossible to 
obtain special aid ; then even the inexperienced surgeon may feel that it 
is his duty to do his best. Such cases are, however, rare ; it is only the 
specially experienced who are qualified to decide as to the fitness of 
operations of expediency, and they alone should perform them. 

Fibrocysts are especially interesting to the surgeon, as being often so 
difficult to differentiate from ovarian cysts, and also on account of their 
frequently extremely rapid growth, leading to urgent necessity for opera- 
tion. Sometimes their cavities are full of blood instead of serum. 
Their pathology is of great interest, but I must refer my readers to the 
article on uterine tumours for further information concerning them. 

Myxomatous Tumours. — One form of tumour deserves a special notice, 
namely, the large, soft, myxomatous fibromyoma : it often attains a size 
so enormous, that the woman appears to be attached to the tumour, 
rather than the tumour to the woman ; it usually burrows deeply into 
one or other broad ligament, or under the pelvic or abdominal parietal 
peritoneum. This tumour is often spoken of as the oedematous fibro- 
myoma. I have seen a case of this kind, in which the whole peri- 
toneum lining the pelvis, and much of that of the lower part of the 
abdominal cavity, was stripped off and raised upon the surface of the 
tumour, so that the latter lay in immediate relation v,dth all the impor- 
tant vessels and nerves supplying the lower extremities, and with the 
ureters. In such a case adhesions not uncommonly form between the 
tumour and these important structures, conditions which have to be kept 
in mind when discussing operative interference. It is not this particular 
kind of tumour only which grows into the broad ligaments, or under the 
parietal peritoneum ; the ordinary fibromyoma not infrequently does so, 



6i4 SYSTEM OF GYNECOLOGY 

and I shall have to refer again to the increased difficulty and danger 
encountered in operating upon such cases. 

Sarcoma of the uterus is very rare, and probably as a primary disease 
seldom appears of a size to form an abdominal tumour ; it is commonly 
intra-uterine, and closely resembles an intramural or submucous fibro- 
myoma becoming polypoid : from these it can only be distinguished by 
its softness and the rapidity of its growth, by the general condition of 
the patient, or by dilatation, excision of a portion of the growth, and 
microscopic examination. Primary uterine sarcoma is also occasionally 
met with as a degenerative growth in old fibromyoma ; it is a degenera- 
tive change in the cellular tissue, and in such cases may form a very 
large abdominal tumour. 

Carcinoma does not occur as a degenerative change in fibromyoma ; it 
is always a primary disease. 

Adenoma and Carcinoma. — As we have three varieties of fibromyoma, 
so we have practically three varieties of carcinoma ; and these again have 
special seats and symptoms. Adenoma is often benign, but liable in 
some cases to recur and become malignant. 

Columnar epithelioma of the glandular type attacks both the body 
and cervix ; squamous epithelioma attacks the os, and is also found in 
the cervical canal, but rarely if ever reaches the cavity. The columnar 
variety is much commoner in the substance of the cervix, where it 
probably arises from the cervical glands, than in the uterine cavity. 
Squamous epithelioma spreads along the surface more than it penetrates ; 
columnar, in its early stages, is often covered in by healthy tissue. I 
need not dwell upon malignant disease, however, as it is dealt with in a 
separate article, in which will be found also the description of the opera- 
tions suitable for its removal, including those which give their name to 
my article. 

In dealing with the operations for simple tumour, for inversion and 
procidentia, and for malformations interfering with natural labour, I 
shall describe them as I am in the habit of performing them, and I shall 
then give a brief description of such additional operative procedures as 
I think worthy of further trial and consideration. 

Supravaginal Hysterectomy (Extraperitoneal). — The stump in this 
operation is secured either by the well-known wire serre-noeud of Koeberle 
— I always use this myself — or by the elastic ligature ; and is fastened 
into the lips of the abdominal wound outside the peritoneum. 

Preparation of the Patient. — This consists in a careful regulation of 
the bowels by mild aperients and enemata, aided by a somewhat restricted 
and light diet, for a week before the operation. An hour before the 
operation the site of the incision, the pubes, and vulva are well washed 
with carbolic soap and water, and the former is covered with a thick pad 
or towel wet with 1 to 20 carbolic lotion, and applied under a piece of 
mackintosh cloth or oil silk and a bandage. Immediately before the 
patient comes into the operation room the nurse should pass the catheter. 
Some surgeons think this is not necessary, but I have seen very experi- 



HYSTERECTOMY 615 

enced operators woniid a full bladder in making the peritoneal incision, 
and I much, prefer the bladder to be empty. I always shave the pnbes 
myself jusu before I operate, and after the patient is under chloroform ; 
it takes a few seconds only, and spares the patient a very disagreeable 
process. The abdomen and chest are protected by an india-rubber sheet, 
a hole proportionate to the expected size of the incision being cut in it, 
and its edges coated with a layer of carbolised adhesive plaster an inch 
and a half broad. 

Operation. — When operating for fibromyoma the incision through 
the peritoneum must be made with a little more care than in ovariotomy, 
as a slight wound of the surface of the tumour may cause severe, or at 
any rate troublesome hsemorrhage, which it may be difficult to check in 
the dense fibroid mass. As soon as the tumour is well exposed, and all 
bleeding from the edges of the abdominal incision is stopped with pressure 
forceps, or fine silk ligatures, as appears more desirable, the hand is intro- 
duced and swept over the abdominal surfaces of the tumour to estimate 
its size, and to detect adliesions if there be any ; it is then passed 
into the pelvis and round the base to see whether it will be necessary 
to remove the ovaries and tubes, and whether these can be included in 
the wire or elastic ligature, or must be tied off separately. I always 
leave one ovary if I can, as I find that, if this be done, the patients 
recover more quickly and completely, and suffer infinitely less at the 
change of life ; especially do they escape the depression which is apt to 
follow complete removal of uterus and ovaries. If the ovaries and tubes, 
or an ovary and tube, have to be tied off, I apply the ligature either by 
transfixion through the utero-ovarian ligament or, if this be impossible, 
as it often is in these cases, through a thin non-vascular bit of the broad 
ligament pretty near the side of the uterus ; then, after tying off the 
ovary and tube, I leave one loop of the transfixing ligatures untied to be 
used in case of any oozing or slipping of ligature during later steps of 
the operation. I pass the serre-noeud wire, or elastic ligature, through 
the puncture made in transfixing the right broad ligament, and again 
through the puncture on the other side if both halves of the broad 
ligament are tied off. If the broad ligaments are not tied off the wire 
merely passes round the base of the tumour, including one broad 
ligament and transfixing the other, so as to exclude the ovary and tube 
on that side. If the tumour be very large and vascular, and the broad 
ligament much opened up, it is desirable to apply two temporary clamps 
on the sides of the uterus, and to cut the broad ligament, between them 
and the ligatures, down to the transfixion punctures ; this greatly frees 
the tumour, and renders the tightening up of the constricting material 
much easier. In many cases it is necessary, before screwing up, to peel 
back the peritoneum both in front and behind, first carrying a nearly 
horizontal incision just through the thin peritoneal covering (so as to 
avoid any visible vessels) from one transfixion point to the other, and 
then to push it down with the fingers, so that the wire or rubber is 
applied on the denuded surface, and all chance of drawing in the bladder 



6i6 SYSTEM OF GYNECOLOGY 

or the ureters is avoided. In the great majority of cases it is, in fact, 
better to push down the bladder in this way ; the posterior enucleation 
is rarely required. After the wire or ligature is tightened up, a strong 
pin with a little screw cap is passed through the uterus from side to 
side just above the wire ; sponges are packed all round, and the whole 
tumour and upper part of uterus are rapidly cut away, special care being 
taken to dry up at once any mucus or fluid which exudes when the 
uterine cavity is cut across. In the great majority of cases section takes 
place near the internal os, and only a small opening, filled with a little 
plug of mucus, is seen in the middle of the stump ; but sometimes a 
large bloody cavity is opened, and then, unless great care be taken, 
fouling of the peritoneum may easily occur. To cleanse this cavity I 
always use absorbent cotton soaked in pure tincture of iodine, or in 
T"oV"o corrosive sublimate solution. There is usually some shrinkage of 
the tissues included in the wire or rubber ligature after the tumour is 
cut away, and, if the enclosed stump be large, it may be necessary to 
tighten up the screw of the serre-noeud several times during the con- 
cluding steps of the operation. 

I have described the procedure without any mention of adhesions ; 
if they are present, especially if they are omental, they often contain 
enormous vessels, and in separating them great care is required to 
avoid serious loss from the uterine side after they are tied and divided 
on their proximal side. Wells' large pressure forceps, and the square- 
ended ones which bear my own name, are very useful for such adhesions. 
Adhesions of large surfaces of intestine are exceeding diflB.cult to deal 
with ; there is no room to apply ligatures before separating, and no 
room, or not firm enough tissue, to apply pressure forceps after separa- 
tion ; thus both surfaces frequently ooze very freely, and much blood 
may be lost during the future steps of the operation : these patients can 
rarely spare blood; sponge pressure is the only way of dealing with 
these oozing surfaces. The raw intestinal surfaces often require fine silk 
to be passed carefully under the peritoneal and into the muscular coat, 
and drawn together bag-mouth fashion, to check the oozing when the 
tumour has been got rid of, and before closing up. If there is likely to 
be much oozing after the peritoneum is closed, I use a Keith's glass 
tube passed to the bottom of the pelvis as in ovariotomy ; and I usually 
bring it out rather high up in the abdominal incision, so as to tie two 
or three sutures between it and the stump, and get room for some dry 
antiseptic dressing between ; for the stump in most cases soon becomes 
septic. For the same reason I always get rid of the tube as soon as 
possible after the operation : I believe the presence of much fluid in the 
drainage tube after the first thirty-six or forty-eight hours is often a sign 
that the tube is irritating a sensitive peritoneum, a point which can be 
tested by slipping a fine rubber tube through the glass one when the 
latter is withdrawn, and the former is left for another twelve or twenty- 
four hours : if the discharge then quickly diminish the tube can be re- 
moved entirely ; if it continue, sufficient drainage is provided. Septicity 



HYSTERECTOMY 6 1 7 



of tlie discharge is sometimes indicated by a prolonged or increased 
flow from the tube, and this without the smallest perceptible odour ; so 
that removal of the glass tube must be carefully considered whenever 
there is anything abnormal either in the quantity of the flow or in its 
duration. 

For ligatures and sutures I still prefer pure Chinese silk twist well 
soaked in 1 to 20 carbolic solution : ISTo. 1 for adhesions, or ]N"o. for 
very fine intestinal work ; No. 2 for sutures ; ISTo. 3 for a si^ecial strong 
suture in these cases above and below the stump, and No. 3 for tying 
the broad ligaments. I sometimes use Xo. 4 for temporary tying off of 
parts during a difiicult operation, but never to leave in the peritoneum. 
I believe that the use of too thick silk is a fruitful source of the pelvic 
swellings, abscesses, and sinuses, about which I am not infrequently con- 
sulted, but which I am happy to say are unkno^Ti in my o^vn practice. 
I have even heard of No. 5 being used to tie an ordinary ovarian 
pedicle ; I do not think I ever had a skein of this size in my possession, 
even in my early days when I had not fully tested the wisdom of using 
the finest silk which would do the work required of it. After the closure 
of the abdomen I pare down the stump as much as possible, especially 
cutting away the inside fibrous and muscular tissue into a somewhat 
cupped shape ; pack it firmly round with dry carbolic gauze ; and then 
with great care apply a little solid perchloride of iron to the cut surface : 
this agent must be used very sparingly and carefully, as it causes a flow 
of acid serum, which is very dangerous if it trickle into the peritoneum ; 
but I am sure it is a great safeguard if properly used. First, if the con- 
striction of the wire relax at all through shrinkage during the first few 
hours after the operation, it effectually prevents any oozing from the 
stump ; secondly, it dries and tans the stump, so that putrefaction from 
the central cavity spreads into it very slowly, and only after some days 
when the parts round about are sealed, and putrefaction is no longer so 
dangerous. I altogether disapprove of sewing over the peritoneal edges 
of the stump ; it is quite useless if the perchloride of iron be used, and 
must in any case shut up material which is much better escaping freely into 
the dressings at once. I have seen half an hour wasted over this sewing 
up of the stump, when the operation had already been long enough to tax 
the patient's strength to the utmost. 

After Treatment. — I sometimes arrange so that the screw of the serre- 
noeud can be exposed without disturbing the rest of the dressing, and a 
screw up given to it every twelve or twenty-four hours ; but this is only 
necessary with very thick stumps, and in most cases it is best to leave 
the dressings undisturbed for several days, and then change everything, 
dusting all the time with a pepper dredger full of finely powdered boracic 
acid. The- second dressing comes about the eighth day, and then alter- 
nate sutures are removed. I generally leave the last two or three sutures 
a good deal longer in these cases than after ovariotomy, as the wounds 
are especially liable to reopen. I suppose the firm wedge of pedicle has a 
tendency to draw open the wound; certain it is that these incisions require 



6i8 SYSTEM OF GYNECOLOGY 

far more care during convalescence than wounds in which the abdominal 
cavity is completely closed. The gaping of a wound after removal of 
the sutures was a much more frequent occurrence in the old clamp days 
of ovariotomy than now ; and in both cases the presence of sepsis in the 
lower part of the wound probably retards firm healing throughout. 

The treatment of the stump varies according to its size and thickness. 
If the part enclosed in the wire be small, I generally screw it up at the 
early dressings, and then leave it alon^ till it sloughs off ; if it be a thick 
pedicle I clip it well down at each dressing after screwing it up, and 
very often clip it down to the wire and pin at the end of two weeks 
and remove them : the remaining slough I leave to separate by itself, 
merely clipping away loose shreds. This necessary sloughing and 
separation of the stump are the weak points in this extraperitoneal 
operation. The process is attended by a certain risk of septic absorption, 
especially if the surgeon is too much inclined to pull the stump about 
at the dressings ; it makes the convalescence tedious ; often five or six 
weeks elapse before it is entirely gone, and even more before the 
granulating cavity is closed up ; and, when cicatrisation is complete it 
often leaves a weak place in the scar. In spite of these obvious dis- 
advantages I still prefer this method in the great majority of cases to 
any of the modifications which have been proposed ; certainly in my 
own hands it has yielded a greater number of good recoveries than the 
intraperitoneal method which I shall now describe. 

Supravaginal Hysterectomy (Intraperitoneal). — In this operation 
the stump is secured by ligatures and sutures, its peritoneal edges are 
brought together over its whole surface, and it is then dropped into the 
peritoneum as is the stump of the pedicle in an ordinary ovariotomy. 
The difference between these two stumps is not, however, sufficiently 
considered by those who advocate this method. Unless the needles 
or ligatures used by the surgeon contain septic materials, the ovarian 
pedicle stump contains nothing but sound uncontaminated tissues ; the 
uterine stump, on the other hand, always contains in its centre a cavity 
which it is impossible to render certainly aseptic ; in some cases, no doubt 
we can clean the uterine cavity with strong antiseptics just before the 
operation, but this procedure is extremely difficult or even impossible 
when the cavity is very irregular in form, and twists and turns about in 
the tumour, and we can never be sure that our applications have been 
so thorough as completely to clean away all possible sources of con- 
tamination : then, if any septic material be left it lies right in the centre 
of the stump, and in immediate contact with tissues rendered specially 
prone to decay by the interference with their nutrition caused by the 
constricting ligatures and sutures, and by the rough handling they have 
had during the separation of the tumour from its base. That this is a 
very grave objection to this particular method its statistics show ; and 
the danger is greatly increased by the occasional occurrence of haemor- 
rhage into the stump which, even when not sufficient in amount to be 



HYSTERECTOMY 619 



dangerous as haemorrhage, adds greatly to the risk of septicsemia from 
the additional material it gives for infection, and from the still further 
interference with the nutrition of the stump tissues. Haemorrhage to 
a fatal issue is also still one of the risks of any complete intraperitoneal 
method, though this has been greatly reduced with increase of experi- 
ence in the securing of the vessels, and in the application of the con- 
stricting ligatures and sutures to the stump. 

I need not recapitulate the steps in the operation, which, up to the 
time when the tumour is freed from adhesions, if any, and brought out- 
side the abdomen, are exactly the same as in the one just described. If 
the base of the tumour be sufficiently clear of the lower segment of the 
uterus for the passing of a ligature round the whole base, including the 
ovaries and tubes — or round one ovary and tube, if the other is to be 
left behind — a strong piece of red rubber tube is passed round, firmly 
drawn up, and its crossed ends secured in a pair of large pressure forceps ; 
then a pin, similar to that used in the other operation, is passed through 
the uterus and one or both broad ligaments, close to the upper side of 
the ligature, and, sponges being packed round the tumour, it is cut away ; 
great care must be taken to leave a sufficiently large stump, and espe- 
cially a broad margin of the peritoneal covering. One or both broad 
ligaments, according as one ovary or both is to be removed, are then 
secured by transfixion in the usual way ; the inner loop of the transfixing 
ligature being left untied for future use if required, as described in the 
extraperitoneal method. The uterine arteries, which can be readily felt 
pulsating, are now separately secured by transfixion, care being taken to 
carry the needle close to the cervix, and to remember how close in this 
situation the ureters lie to the uterine arteries. The stump is then care- 
fully pared down to the size and shape in which it is to be left, and a 
deep cup made in it by paring out its centre ; the mucous membrane is 
cut away right down to the level of the constricting ligature : then, if it 
be possible, a fine probe armed with cotton wool soaked in some powerful 
antiseptic should be passed through the centre of the stump into the 
vagina ; some operators use the cautery for this, but I do not think 
the plan a good one ; it may destroy the septic material, but it leaves a 
layer of dead tissue, and below this a layer of damaged tissue in the 
stump, just when we want everything to be as healthy and as capable 
of quiet repair as possible.^ After the cleansing is as perfect as it can 
be made, the edges of the mucous opening are carefully brought together 
by a few points of fine silk interrupted suture which are cut short ; then 
the deeper parts of the muscular tissue are brought firmly together by 
another row about half an inch from the first sutures ; then the constrict- 
ing band is relaxed, and pressure forceps are applied to bleeding points, 
which, however, will be few if the broad ligaments and uterine arteries 
have been efficiently dealt with : after a pause, to allow anything that 

1 It will be seen farther on in this article, that recent observations show that in most 
cases the cervical canal does not contain putrefactive organisms, and this demonstration 
may modify our practice in this particular. 



620 SYSTEM OF GYNECOLOGY 

is going to bleed to show itself, all the points in the forceps are carefully 
secured by fine silk passed with a fine needle under the open mouth 
of the vessel, the pin is removed, and the peritoneal edges are brought 
firmly together over the surface of the stump, first by a row of inter- 
rupted sutures, and then by a fine continuous suture, so applied as to bury 
the first row between inverted peritoneal surfaces ; the stump is then 
allowed to sink back into the pelvis, and the abdominal incision entirely 
closed, unless it be thought desirable to drain, in which case a Keith's 
glass tube is passed down beside the stump, and its mouth closed with the 
usual rubber sheet and sponge dressing. Some of the cases in which I 
have performed this operation have made remarkably quick and satis- 
factory recoveries ; others have had evidence of serious trouble in and 
around the stump : in one case the whole cervix sloughed out and was 
discharged into the vagina, the patient eventually making a good recovery. 
But what has chiefly deterred me from more frequently operating by 
the intraperitoneal method is the occasional fatality from haemorrhage. 
I lost some cases myself in my early operations, and though I have not 
had this misfortune now for many years, I see occasional reports of 
them : moreover, I have reason to know that others happen which are 
not reported ; and I greatly doubt whether the intraperitoneal method 
would hold its own, if really reliable statistics of the extra- and intra- 
peritoneal methods could be obtained. 

Comparison of Results obtained by the Two Methods. — In order to 
satisfy myself, in so far as my own results go, whether my impressions 
were correct, I have been most carefully through my case books, and 
weeded out all the cases in which some unusual complication — such as 
pregnancy, the presence and removal of a large ovarian tumour, or the 
presence and removal along with the fibromyoma of a large suppurating 
calculous kidney — could specially affect the result. I then classified 
the cases according to the extent of the operation, and the method of 
dealing with the remains of the uterus. I find that the results completely 
bear out the impressions I had formed, or rather support still more 
strongly the extraperitoneal method, with Koeberle's serre-noeud for the 
ordinary run of cases. Complete removal of the uterus, including the 
cervix, has succeeded still better, all my cases having recovered ; but 
they are few, and the method is not suitable for all cases. 

I have not only weeded out such cases as I have named above, but 
I have put into a separate class those formidable cases in which a very 
large tumour grows either into (between the folds of) the broad liga- 
ment, or under the peritoneum ; cases in which a large amount of enu- 
cleation has to precede the formation of a pedicle, and in which a large 
ragged cavity is left beside the stump, either in the broad ligament or 
under the parietal peritoneum. At a recent discussion in America it was 
proposed, and I think very properly, to consider these cases as a separate 
class. Operations for the removal of such tumours are among the most 
formidable the surgeon has to perform, and among the most dangerous 
to the life of the patient. It is absurd, therefore, to class them with 



HYSTERECTOMY 621 



cases in which the wire of the serre-noeud encloses the whole uterine 
pedicle and one or both ovaries ; or in which the wire readily takes the 
pedicle after the ovary or ovaries have been tied off. 

The results of my research are as follows : — Cases in which the serre- 
noeud could be employed without extensive enucleation ha^e a mortality 
of just under 8 per cent. Cases in which a formidable enucleation has 
to be done have a mortality of 32 per cent. Cases treated by ligature 
and suture (intraperitoneal) have a mortality of 50 per cent. Eemovals 
of solid outgrowths (subperitoneal tumours), or of pediculate fibrocysts, 
or enucleation of cysts, in all of which the uterine cavity is not opened 
into, have only a. mortality of 7 per cent. Those in which the cavity is 
opened, but the body of the organ not removed, have in my experience 
been the most fatal of all ; but their number is too small to permit a 
statistical appreciation of results. 

Cases in which the whole uterus has been dissected out have, as I 
have said, all recovered. 

In looking at these results it must be borne in mind that they include 
all my early work when the whole of these operations were in their 
infancy, and only occasionally attempted ; and as I early became dis- 
satisfied with the intraperitoneal method, my results under this head 
belong to my early work alone : doubtless had I worked more at it the 
results would have improved, but the gap between 8 per cent and 50 
per cent wants a good deal of bridging over. Then also it must be 
borne in mind that this 8 per cent mortality includes all my early work 
with the serre-noeud ; and, as practice with it has reduced this mortality 
by fully one-half, the cases which are suitable for the serre-noeud, and in 
which there is no unusually serious complication, may fairly be said in 
experienced hands to have a mortality of only 3 or 4 per cent. My im- 
pression is that my results in the series of enucleation cases would have 
laeen better if I had performed a true hysterectomy, and excised the 
remains of the cervix as well. It is the combination of the large 
ragged cavity, from which the base of the tumour has been enucleated, 
with the sloughing stump which leads to the high mortality in this class 
of cases. 

The manifest objections to the extraperitoneal treatment of the 
stump, and the search after some surgically complete and satisfactory 
intraperitoneal method, have led to a large number of suggestions ; some 
good and likely to bear good fruit, and more bad and sure to die prac- 
tically stillborn. American surgeons are now rather taking the lead in 
this new departure. German, French, and Belgian surgeons run them 
hard, however, with novelties in method, and some excellent results. 
Great Britain seems to be dropping a little behind, and resting on the 
extraperitoneal method ; though we shall certainly have to reconsider 
the question with such results from intraperitoneal work as have been 
obtained by Baer, Zweifer, Chrobak, Pean, Eichelot, Doyen, Jacobs, 
Martin, Bardenhauer, Eastman, and others. 

I now proceed to describe some of the suggested modifications in the 



622 SYSTEM OF GYNECOLOGY 

intraperitoneal methods which. I think most valuable and likely to sur- 
vive ; and I shall also mention some that I do not think well of in 
order to point out objections and to warn off my readers from 
them. 

Before proceeding to describe some of the best of the many modifica- 
tions recently suggested and practised in the performance of this operation, 
it will not be out of place to give a brief account of the early work at the 
operation, and its gradual establishment among the recognised surgical 
procedures. The early operations were nearly all stumbled into when 
the surgeon expected to perform ovariotomy ; and, as might be expected 
of an operation which still, with all our advances and experience, often 
taxes to the utmost the skill and nerve of our most expert specialists, 
they usually ended in disaster. Then came Koeberle's serre-noeud and 
a new era dawned. Pean in Paris, Koeberle' himself, Kaltenbach and 
Hegar in Germany, Keith in Scotland, and Bantock and myself in London, 
each did a considerable number of cases, and chiefly difficult cases with 
large tumours, because it was only in such that it was considered jus- 
tifiable to operate at all ; and yet the success was very fair. Now and 
again it was found impossible to apply the serre-noeud, and some intra- 
peritoneal method was adopted, with some increase of knowledge for 
the surgeon, but only very occasionally with a result satisfactory to the 
patient. AVhen an intraperitoneal case did succeed, the convalescence 
was more rapid, and the immediate result more satisfactory, than with 
the extraperitoneal method. I did my first operation at the Samaritan 
Hospital in January 1877, choosing deliberately the intraperitoneal 
method, and securing the stump by silk ligatures with a successful result, 
nearly two years before Schroeder first called attention to that intra- 
peritoneal method which will always be associated with his name. 
Disappointed by results in succeeding cases, I tried to improve my 
intraperitoneal method, but without much success. I had not then 
fully adopted Listerism in abdominal surgery, and I fell back upon the 
extraperitoneal method, using Koeberle's serre-noeud, and a single pin 
devised by myself to support the stump. Schroeder first suggested his 
method in 1878, but did not fully publish it, with cases, till 1882, and 
he had a mortality of 30 per cent, a rate which was never improved to 
the end of his work, which consisted of 164 cases, published by Hofmeir. 
Some of his followers, however, were much more successful. Breunicke 
of Magdeburg had a series of twenty-one cases, all successful. Fritsch of 
Breslau, having by the extraperitoneal method reduced his death-rate to 
7 per cent, was still dissatisfied, and went to Schroeder's method, with 
what success I do not know. 

Baer'^s Operation. — In 1891 B. F. Baer of Philadelphia first performed 
this operation, and in the following year he published the method with 
some successful cases. I give it the first place among the new procedures 
which I describe, because I think it is the most surgical, and at the same 
time the most likely to give good results in the hands of competent imi- 
tators. His own results have been splendid. I give the details of the 



HYSTERECTOMY 623 

operation as first published by him in the Transactions of the American 
Gynaecological Society, vol. xvii. 1892, p. 234. 

The ovaries are tied off by a single ligature passed close to the side of 
the tumour, and not including the tubes, the ligature being also passed 
through the outer edge of the broad ligament ; then the uterine arteries 
are separately ligatured on each side, the tumour and uterus are cut away, 
any points of haemorrhage are secured by separate ligatures, and the 
cervical stump is allowed to drop back into the peritoneum. The retrac- 
tion aids in stopping any small haemorrhage, and the edges of the broad 
ligament close in over the stump, so that there is no need for suturing of 
flaps over it : he does not object to this, however, if it appear necessary in 
any special case. The mucus plug in the cervical canal is not disturbed 
either before or during the operation ; and on this, and on the absence of 
all ligatures or sutures in the stump, he lays great stress. He claims for 
this procedure that the vaginal portion of the cervix maintains its position 
as the keystone of the vaginal arch, and preserves the strength and shape 
of the lower part of the abdominal cavity. He does not fear any serious 
haemorrhage from the cut surface of the cervix if the ovarian and uterine 
arteries have been securely ligatured ; and he does not believe in the 
necessity for any drainage in abdominal surgery. The method at once 
commends itself to the surgical mind. Doderlein's researches, which 
show that the cervical canal, when not interfered with, does not contain 
septic organisms, give great support to Baer ; but in many patients the 
cervical canal has been interfered with before they come to the operation ; 
in others the section has to be made through a large open canal full 
of clot or bloody mucus, yet in Baer's papers I fail to find any suggestion 
for dealing successfully with these cases. The plug does frequently exist, 
and I have already in this paper referred to its presence, but I did not 
appreciate its value till I read Baer's paper. 

Baer published a second paper on his method in the same Transactions, 
vol. xviii. p. 62. In this he says : " The vital principles in supravaginal 
hysterectomy are — first, control of haemorrhage by ligature of the blood- 
vessels in the broad ligaments ; second, non-constriction of the cervical 
tissues, so that there shall be no cause for suppuration ; and, third, non- 
disturbance of the cervical canal, so that sepsis from the vagina may be 
prevented." 

Dudley and Goffers Operation. — I mention this operation next, not 
because I wish to commend it, but because the authors have claimed for 
it that it is like Baer's operation, — a claim which, to my mind as to 
his, shows how little they have appreciated the points of his procedure. 
They ligature the cervix by ligatures passed under or inside its peritoneal 
covering, and then they cover in the raw surface with large peritoneal 
flaps cut without any other tissue in them, and sewn over the stump so 
as to shut it off from the peritoneal cavity. What is the result ? That 
in order to let out the pus which often accumulates between its raw 
surface and the flaps, they have, soon after operation, to place their 
patients in the position for dilatation of the cervix. This result might 



624 SYSTEM OF GYNECOLOGY 

have been easily foretold ; for they first do all they can to lower the 
vitality of the stump by ligaturing and separating it from its peritoneal 
covering, and then they shut it away in a closed space without drainage, 
or any possible escape for discharge ; unless, indeed, the cervix be dilated 
and forced open by the accumulation. It is a return to my method of 
January 1877, except that I did not shut up the stump by sewing over 
the flaps. Inflammation shut it up for me at the bottom of the pelvis, 
and then the accumulating pus forced open the cervical canal with a 
little help from me, the pus and a slough were discharged, and the patient 
eventually got well ; but not by my surgery. Goffe has published ten 
cases operated upon on this method by himself and two other surgeons 
with a 20 per cent mortality. In any large series I should expect it 
to be much higher. 

Eastmaii and Chrobak have modified Baer's operation, and again, I 
venture to think, in a decidedly retrograde direction. They tie the 
arteries as he does, cut across the cervix, and then burn a hole through 
the stump into the vagina, putting a gauze drain through the hole. 
Then they suture the cut edges of the peritoneum so as to shut out the 
stump. This is really making an extraperitoneal operation, of somewhat 
similar character to the operation of Byf ord to be next described : the 
same objections I shall have to raise to Byford's procedure apply also 
to this; practically a damaged stump is extruded into the vagina, to 
suppurate, and most probably to slough. 

ByforcVs Operation. — In 1889 Henry T. Byf ord, of Chicago, advo- 
cated the carrying of the stump of the cervix into the vagina, through 
the anterior cul-de-sac, by separating the uterus and bladder. After the 
broad ligaments have been secured, the base of the tumour is temporarily 
secured by an elastic ligature and pin. The uterus and tumour having 
been cut away, the stump is ligatured in several portions, the ligatures 
being left long : an opening is then made into the vagina behind the 
bladder, and the stump is carried into the vagina and clamped there, the 
edge of the peritoneum, separated with the bladder, being sewn to the pos- 
terior surface of the extruded cervix to shut off the peritoneal cavity. 
Ancient history, indeed, when we get back to long ligatures and a 
clamp ! This operation courts disaster at every turn. First the cervical 
stump is damaged by temporary pin and elastic ligature ; then its vitality 
is further impaired by its being ligatured in several pieces ; then it is 
twisted out of its natural position into the vagina ; then its posterior 
surface has a lot of sutures passed into it to shut off the peritoneum; 
and, finally, it is clamped in the vagina, where, with its long ligatures 
and septic neighbourhood, it is far more likely to slough than to live. 
Mainert suggested carrying the stump into the vagina through an 
opening in the posterior cul-de-sac ; another modification proposed was 
dilatation and turning the cervix inside out, an operation which, I imagine, 
is easier to suggest than to perform. Another equally awkward and 
dangerous suggestion was to cut down through the cervix itself into the 
vagina, and then to invert it. All these operations seem to me equally 



HYSTERECTOMY 625 



vicious in principle, and only vie with one another in difficulty of per- 
formance. Kelly of Baltimore, suspending the stump in the abdominal 
cavity by long ligatures, also made a retrograde step in surgery. If 
any one thing delayed the progress of abdominal surgery more than 
another it was the use of the long ligature. To find it turning up 
again is astounding ! 

PoWs Operation. — An account of this operation was published by 
its author, William M. Polk of New York, in the Transactions of the 
American Gynmcological Society, vol. xvii. 1892, p. 215 ; and, though I 
believe he has now abandoned it in favour of complete extirpation, it 
has been sufficiently practised, both by himself and others, to make it 
desirable that it should be described in this article. I have never 
practised it myself because I was not favourably impressed either by 
its " technique," or by its results as seen in the hands of Polk's disci- 
ples in this country. It was specially introduced for that most formid- 
able class of cases, to which I have already referred, in which a 
considerable amount of enucleation is necessary before the base of the 
tumour can be reached and secured. Haemorrhage, septicaemia, and pro- 
longed suppuration were among its immediate results, as I saw them ; 
and, in cases which recover, hernia on a large scale must I am sure be 
common as an after result. He separated the broad ligaments, round 
ligaments, and vessels from the tumour ; then placed a rubber ligature 
round the base of the whole mass (this would be quite impossible of per- 
formance in many of the cases in which I have operated) ; then made a 
circular incision all round and stripped down the peritoneal covering, 
the posterior part carrying some of the muscular tissue as well ; the 
uterus and tumour were amputated within this sac, and all the visible 
vessels ligatured; then the rubber ligature was removed, any other bleed- 
ing points were secured, and the cut surface of the stump was seared with 
the actual cautery, which was also passed through the cervical canal into 
the vagina. The edges of the sac were then sutured to the edges of the 
opening in the parietal peritoneum by strong catgut, and to the whole 
thickness of the abdominal incision by the ordinary abdominal sutures ; 
the opening left was stuffed with iodoform or bichloride gauze, and the 
whole covered with an ordinary dressing. 

Polk is a strong advocate for ligature of the uterine arteries at some 
distance from the cervix and outside the ureters, because he maintains 
that in this situation the vessel is met with as a single trunk, and haemor- 
rhage from its branches is avoided. I have not been troubled with 
haemorrhage in the few cases in which I have ligatured the uterine 
arteries close to the cervix, and I cannot but fear for the ureters by Polk' s 
method; it is not always easy to isolate the artery entirely as he 
advises. A study of his own diagram emphasises the danger to the 
ureter, and shows how useless it is to ligature the branches referred to. 
He advises also a sort of chain of ligatures in tying off the broad ligaments. 
I have always found that a single ligature is sufficient, though I always 
transfix with a double silk and leave one loop untied in case of any 

2s 



626 SYSTEM OF GYNECOLOGY 

emergency. I doubt both the necessity, and the advisability, of so tying 
the uterine artery as to secure also its paravesical and vaginal branches. 

The difficulty in dealing satisfactorily with the cervical stump has led 
many operators to consider whether it would not be better to remove the 
stump entirely, thus performing complete extirpation of the uterus. I 
have performed this operation four times ; all the patients made excel- 
lent recoveries, and the after results have been very good. I have 
recently examined two of the patients, and have been agreeably sur- 
prised by the satisfactory condition of the vagina : the shortening and 
shrinkage is not nearly so marked as in some cases in which the cervical 
stump has been left, and the vaginal vault has preserved its firmness and 
shape ; so that I think the objection to the operation in this direction 
need not deter us from its x)erformance in suitable cases. 

I will briefly describe the operation as I perform it, and then refer 
to the modifications now practised both by Eastman of Indianapolis, and 
Chrobak of Vienna, and also to the modifications of other operators. 

Complete Abdominal Hysterectomy. — The broad ligaments are 
ligatured off as in the other methods ; if it be desirable to leave one 
ovary this can readily be done by transfixing and tying between it and 
the uterus. To stop back bleeding pressure forceps or temporary clamps 
are applied to the uterine side of the cut broad ligaments ; the anterior 
and posterior peritoneal coverings of the uterus are incised and peeled 
back, fine ligatures or pressure forceps being applied to bleeding points ; 
the finger is then pushed down between the tied off broad ligaments and 
the side of the uterus, till the uterine artery is felt pulsating, and it is 
then ligatured by transfixion, taking care to keep close to the cervix so as 
to avoid the ureter, the opposite one having been secured ; the vagina 
is opened, behind the bladder, by cutting on the point of a sound pushed 
up through the vagina by an assistant ; a sponge is pushed through the 
opening into the vagina to prevent fluid passing from it into the peri- 
toneum ; the tumour is held well up in a central position so as to drag 
slightly on the top of the vagina, and then the point of a long pair of 
scissors, curved on the flat, is run quickly round the top of the vagina, 
the tumour, uterus, and cervix are lifted away, and any bleeding points 
in the cut edges of the top of the vagina are rapidly secured by pressure 
forceps. All the bleeding points are then secured with fine carbolised 
silk, either by simple ligature or transfixion, care being taken to draw the 
edges of the broad ligament and divided peritoneum as much together in 
this process as possible, so as to reduce the size of the opening into the 
vagina. The vagina is well sponged out and plugged lightly with a long 
strip of iodoform gauze ; a Keith's glass tube is placed in the pouch of 
Douglas so that any blood or serum running back into this pouch from 
the cut edges of the vagina and peritoneum may be rapidly removed, and 
the abdominal incision is entirely closed round the drainage tube : this 
tube is only left in for 24 or 48 hours, by which time oozing has ceased 
and the vaginal plug has established a good capillary drain from the top 



HYSTERECTOMY 627 

of the vagina to the vulva ; the orifice of the latter is kept constantly 
dry by a frequently changed plug of salicylic wool, or other dry anti- 
septic absorbent material. For the first few days the urine is removed 
every few hours by the catheter, to avoid soakage into the vaginal plug. 
I prefer to leave this plug in place till the fifth or sixth day, if the con- 
dition of the patient indicates that it is keeping sweet, as it acts as a 
valuable support to the upper part of the vagina during the early days 
of healing, and is a good capillary drain ; when it is withdrawn I care- 
fully syringe the vagina myself with an antiseptic douche (usually warm 
1 to 2000 corrosive sublimate, or straw-coloured iodine and water, using 
the latter till it returns without losing its colour). I repeat the douche 
night and morning, as long as the iodine-and-water solution is decolorised, 
or as long as there is any discharge. I never put any fresh plug into 
the vagina, as it is not at all necessary, and I think the manipulations 
necessary for its introduction are a source of danger. 

I have never been able to understand the great trouble taken by most 
abdominal surgeons to shut off stumps and raw surfaces from the peri- 
toneum : all experience shows that if the operation be aseptic, effusions of 
blood are much more rapidly and harmlessly absorbed by the peritoneum 
than by torn and cut cellular tissue ; and experience likewise teaches 
that adhesions to any raw surface left free in the peritoneum are very 
rare. Damaged surfaces, on which peritoneum remains, much more 
frequently adhere. If asepticity be not quite assured it is easy to drain 
with a glass tube. In my opinion, it is infinitely more dangerous to 
shut up cut and torn tissues in a cavity like the vagina. 

Bardenhauer and Eastman deserve the chief credit for the perfection 
of the operation of complete extirpation. Chrobak, a close follower of 
Eastman, has also been most successful with his cases of complete extir- 
pation. This latter operator performed the operation in two stages, first, 
he removed the uterus and tumours as in ordinary supravaginal hyste- 
rectomy, and then he removed the cervical stump. Early in 1891 he 
reported a series of 17 successful cases by this method ; but in a later 
paper in the same journal (p. 713) he advocates retention of the cervix, 
ties the uterine arteries, dissects off peritoneal flaps, excises the tumour, 
burns through the cervical canal with Pacquelin's cautery, puts a gauze 
drain through into the vagina, and sutures the peritoneal flaps. 

Polk, Krug, and Edebohls have given up doing the operation in two 
steps, and they remove tumour, uterus, and cervix in one mass much in 
the same way that I have done ; but they suture the opening in the 
peritoneum, a proceeding which I believe to be unnecessary. Polk has 
reported 18 cases with two deaths, and Krug 18 cases also with two 
deaths. Zweifel of Leipzig has reported 51 cases with only two deaths. 
He uses a chain of ligatures all interlocking, silk for the broad ligaments 
and catgut for the cervix, cuts peritoneal flaps and ligatures inside them, 
passes Pacquelin's cautery through the cervical canal into the vagina, 
and finally sutures his peritoneal flaps together so as to shut off the 
field of operation from the peritoneum. 



628 SYSTEM OF GYNAECOLOGY 

French and Belgian Surgery and Forcipressure. — Instead of using 
ligatures, the French and Belgian surgeons have for some time past been 
using successfully various forms of forceps for clamping the broad liga- 
ments. Mr. Greig-Smith in this country some years ago introduced a 
vaginal clamp for application to the broad ligaments in vaginal hyste- 
rectomy, which I ventured slightly to modify ; but I am not aware that 
it has been much used. In the hands of Richelot, Doyen, Jacobs, and 
others, remarkable success has been obtained in the removal of small 
fibroids by the vagina by the use of various forceps. Hichelot has had 
38 cases with only one death ; Doyen, 22 with one death ; and Jacobs 
of Brussels, 22 with no death. These results compel our admiration 
for the surgical skill of the operators ; but in this country we have not 
yet become convinced of the necessity, or even of the advisability, of 
operating at all upon these small fibroids. 

For the cure of moderate sized tumours I still prefer simple removal 
of the ovaries and tubes ; and I believe that the patient is in better con- 
dition after this operation than after a total extirpation of the uterus by 
the vagina, though the cure may be less showy. I am sure that there is 
something faulty in the methods of operation, when surgeons do not 
get good ultimate results from this operation ; in my hands the results 
have been entirely satisfactory, and I am constantly seeing old patients 
whose condition thoroughly bears out this statement. Before pro- 
ceeding to describe this operation, I will summarise the various methods 
of performing hysterectomy. The oldest extraperitoneal method with the 
wire serre-noeud of Koeberle, in spite of all that has been and can be said 
against it, still is probably by far the commonest procedure. The elastic 
ligature and pin never seems to have become a generally favourite method. 
Total extirpation, I think, now comes next ; and would, I think, soon 
hold the field alone, if the difficulties with regard to the roof of the 
pelvis, and the damage to the vagina, could be satisfactorily overcome. 

Of the intraperitoneal methods, that of Schroeder is practically aban- 
doned on account of its mortality ; Baer's operation is certainly the most 
promising of these methods. Then there are the various pressure forceps 
and clamps, introduced by Hichelot and others, for total extirpation 
without ligatures. The various methods for extruding the stump of the 
cervix into the vagina are procedures which I venture to predict will 
rapidly disappear. The method which will enable the surgeon to per- 
form an absolutely aseptic operation will be the operation of the future ; 
but the difiiculties are so great that it has not yet been introduced, and 
when it is it will also have to combine with asepticity, a sound abdominal 
scar and a practically normal vagina. 

It is evident that all the difficulties of the operation still centre 
round the method of treating the stump ; time and wider experience 
alone can settle which method is best. 

Removal of Ovaries and Tubes for Cure of Fibromyoma. — I must now 
describe the operation for the removal of the ovaries and tubes (uterine 
appendages), a procedure which, in a certain class of cases, may properly 



HYSTERECTOMY 629 

supplant the more serious mutilations we have been considering. Before 
commencing an operation for uterine fibromyoma, I always tell the patient 
and her friends that, though it is my intention to remove the appendages 
or to perform hysterectomy as the case may be, I must be free to revise 
my decision, if I think it advisable to do so, after I have opened the 
abdomen ; for when we can see and handle the parts, we find cases in 
which the one operation is obviously more suitable than the other. 
Eemoval of the appendages is undoubtedly the proper operation to 
perform in those cases in which the fibromyomas though small, and still 
confined to the pelvis, are causing serious hsemorrhage or serious pain. 
Hysterectomy, in most of such cases, would be especially di£6.cult and 
proportionately dangerous ; while the removal of the appendages may 
usually be accomplished without any unusual dif&culty, and with every 
prospect of a cure, immediate as regards the haemorrhage or pain, and 
more gradual as regards the disappearance of the growths, which cause 
these outward symptoms. Another class of cases for which removal of 
the appendages may often be substituted for hysterectomy, is that in 
which we have to deal with a moderate sized tumour, involving more or 
less of one uterine wall ; the ovaries being still separated and separable 
from the mass by manageable pedicle ; tumours varying in size from that 
of a co3oa-nut to that of the head of an ordinary child of ten or twelve. 
Such cases often yield very good results from this operation, the tumour 
disappearing quickly after it, and leaving the patient in very good and 
comfortable condition. If, however, in such a case the ovaries, or one 
ovary, are found sessile, and so flattened out over the tumour that it 
is difficult to tie their bases without fear of secondary hsemorrhage, or 
without leaving some portion of ovarian tissue behind, it is far better to 
proceed to hysterectomy. There are cases which are equally suitable for 
either procedure ; then we may be guided by what we have already said 
to the patient, or by her probable future : thus in the case of a young 
married woman, or of one who is going to marry, it may be advisable to 
perform hysterectomy and leave an ovary ; whereas in a woman nearing 
the menopause, and either childless or unmarried, it may be better to 
remove the ovaries. The need for a quick recovery may also influence 
us in deciding the matter ; recovery after hysterectomy being usually 
much quicker than after removal of the appendages, when the tumour 
is left to be gradually absorbed. Fibrocysts, blood-cysts, myxomatous 
or oedematous fibromyomas, and those which are degenerating rapidly 
(breaking down), are not suitable cases for this operation. 

There can be no doubt that the operation of removal of the appendages, 
in suitable cases, is less dangerous to life than that of hysterectomy, and 
in my own hands its after results have been excellent. I know of two 
cases only in which the tumours have not entirely disappeared ; and one 
of those, for reasons too long to enter upon here, is not a test case : the 
other would, I believe, have recovered if she had given herself time, but 
she got into the hands of the electricians. The objections to the opera- 
tion are that, in order to obtain a perfect result, it is absolutely necessary 



630 SYSTEM OF GYNECOLOGY 

to remove both ovaries entirely ; and that in many cases there is a rather 
slow convalescence, one which may extend even to a matter of years, 
before the tumour is entirely absorbed, and the pelvic discomforts of its 
presence entirely gone ; the discomforts incident to change of life, too, 
are usually more marked after this operation than after hysterectomy. 
When it has been decided to remove the appendages, the operation is 
precisely similar, in its early steps, to those already described. After 
carefully opening the abdomen and stopping all oozing from the abdominal 
incision by pressure forceps, or fine carbolised silk ligatures, the ovaries 
and tubes are sought for and, if found to be sufficiently free from the 
tumour, are tied off by transfixion just as in ovariotomy for tumour. I 
always ligature both pedicles securely before cutting anything away, 
because the necessary manipulation of the tumour in getting hold of and 
ligaturing the second set of appendages, may put a dangerous strain upon 
the pedicle already tied ; for these pedicles are always rather short, so 
that not much of a stump remains on the distal side of the ligatures. I 
am always careful in transfixion to puncture through the utero-ovarian 
ligament, if this be possible ; as puncture through it is free from risk of 
haemorrhage, and gives a firm hold for the ligatures : but sometimes the 
ligament is so spread out over the surface of the tumour, that it is almost 
impossible to transfix it without risk of wounding some of the veins 
immediately under it ; in this case it is better to select a thin and blood- 
less bit of the broad ligament for puncture. Puncture of a vein is, in my 
opinion, the great risk in this operation 5 even in ordinary ovariotomy it 
is apt to lead to phlebitis, but in the latter operation it is generally possible 
to get a fresh transfixion behind the vein puncture, while in the operation 
under discussion there is rarely room to do this, and one has to leave the 
silk passing through the vein and trust to control the oozing by another 
ligature merely tied behind it. In one case I had gangrene of the leg 
from phlebitis following puncture; and in another case, though the 
symptoms were somewhat obscure, I always myself believed that some 
clot and trouble in the pelvic vein led to the death of the patient. I 
transfix and tie both pedicles ; I then cut away both ovaries and tubes, 
and then apply a third No, 2 carbolised Chinese twist ligature round the 
whole of each pedicle. I always sponge out the pelvis, too, before com- 
pleting the ligature. It is rarely necessary to drain in these cases, which 
is fortunate, for it is very difficult to get the glass tube to lie nicely 
behind the tumour without bringing it out so high in the incision that 
it lies awkwardly among the intestines and is apt to irritate them. 

Hysterectomy for Procidentia. — This operation I have never per- 
formed. I have never seen a case which seemed to me to justify so 
extreme a proceeding ; indeed, I have never myself met with a case in 
which the uterus could not be kept up, so as to make the patient com- 
fortable, by some form of vaginal support. I can understand, however, 
that some patients would rather run the risk of operation, than have the 
constant trouble and annoyance of a support. The removal of the uterus 
should in such a case be performed through the vagina ; and as I have not 



HYSTERECTOMY 631 



had occasion to refer to kolpo-hysterectoniy, I will briefly describe the 
method I prefer. Kolpo-hysterectomy for malignant disease is, I under- 
stand, included in the article on '• Cancer of the Uterus," and does not 
fall within my province. 

Kolpo-Hysterectomy . — For some days before the performance of this 
operation the patient should be prepared by frequent large anti- 
douches. I think it is best to vary them, using in turn 1 to 60 
carbolic acid, 1 to 1000 corrosive sublimate, and iodine and water of 
deep straw colour. I always begin the preparation by thoroughly 
cleansing the uterine cavity with tr. of iodine applied on cotton wool by 
means of a Playfair's probe, and, if possible, a free washing out with 
iodine and water through a double action tube. For the forty-eight 
hours preceding the operation the vagina should be washed out 
thoroughly, every six hours, with a full douche of one or other of the 
antiseptic solutions named above. The last douche is to be given just 
before the patient is placed on the operating table. 

The vulva should be thoroughly washed with carbolic soap night and 
morning for some days before the operation, and again when the last 
douche is given ; especial attention being given to the folds between the 
thighs and inside the labia, and between the latter and the clitoris. I 
always shave off what hair I wish to be removed after the patient is 
under chloroform, as it only takes a few seconds, and is a very disa- 
greeable proceeding if done during consciousness. The patient should be 
placed on her back with head and shoulders low, and the legs supported 
in the lithotomy position by Clover's crutch. The operator should sit 
at the foot of the table, with his back to a window. A strip of iodoform 
gauze is passed into the uterus so as to block the cervical canal, and 
the cervix is seized by a strong locking volsella with curved handles, 
so that an assistant can move the uterus about freely, as directed, with 
as little obstruction to the vaginal outlet as possible. The operator 
pulls the uterus well down to the outlet, and then hands it to the assist- 
ant, who moves it backwards and forwards and from side to side as 
required during the subsequent steps of the operation. 

The operator now divides the mucous membrane all round the cervix, 
as high up as the vaginal reflexion will admit, taking care to make only 
a superficial division at the sides over the vessels, and cutting well 
through into the cellular tissue in front and behind. He then pushes 
back the mucous membrane towards the bladder, and towards the pouch of 
Douglas, till the sense of resistance warns him that the limit of safety is 
reached. Then he either pushes his finger through into the pouch of Doug- 
las, or perforates it with Lister's sinus forceps, expanding the blades as 
they are withdrawn to allow the finger to pass in. The peritoneum is then 
divided right across the back of the pouch, and next between the bladder 
and uterus, the puncture and section here being aided by the finger hooked 
over the fundus. A large carbolised sponge is now pushed into the lower 
part of the peritoneum to keep back the intestines and omentum, and pre- 
vent any fluid or air from the vagina being sucked into that cavity ; and 



632 SYSTEM OF GYNECOLOGY 

the securing and separating of the broad ligaments is then undertaken. 
Different operators differ greatly in their method of performing this 
part of the operation. I prefer to snip the ligaments gradually through 
with scissors, keeping the blades close to the sides of the cervix, and 
seizing and tying each bleeding point, generally by passing a fine silk 
under the open mouth of the vessel, a much slower proceeding than 
many of those employed, but one having the merit of being very sure. 
The operator is absolutely free from risk of secondary haemorrhage ; he 
does not leave great pieces of tied tissue to suppurate or slough ; and he 
sees exactly at each step whether the tissue cut through be normal or 
infiltrated. If the uterus is firmly dragged down and over to the side 
opposite to the one being divided, the trouble from back bleeding from 
the uterus is bat little ; but if there be any, it is easily checked by the 
application of a slender clamp, or long, thin-bladed forceps. When both 
sides have been divided the uterus is drawn down and removed, the 
sponge is removed from the pouch of Douglas, the vagina is packed up 
lightly to the circular incision at the top with iodoform gauze, care being 
taken not to make this packing separate the edges of the wound, and a 
sanitary towel, fastened on by a T bandage, completes the dressing. The 
sanitary towel should be frequently changed. The vaginal plug can in 
most cases be safely left for five days to a week, when it is gently with- 
drawn, and the vagina carefully douched with iodine and water. I 
always do this myself night and morning for the first week after the 
removal of the plug. I never use any sutures to bring the edges of the 
divided peritoneum together, and I find that if the plugging is lightly 
and properly done, it gives just the necessary support, the edges fall 
naturally together, there is no fear of intestinal prolapse, and drainage 
into the plug, and through it, is free and efficient. I always have the 
catheter used while the plug remains in, to avoid wetting it with urine. 
In performing this operation for procidentia, it is necessary to remem- 
ber that the bladder and ureters, and even the intestines, are very apt 
to be much displaced, so that much greater care is required in the cutting 
parts of the operation. In such cases the method I employ is especially 
likely to avoid injury to these displaced organs. 

I sometimes ligature the uterine arteries by transfixion before com- 
mencing the gradual division of the broad ligaments. This is not always 
easy to do, but, if it can be done, it undoubtedly saves haemorrhage, and 
renders the rest of the operation easier. Some operators transfix and 
tie the broad ligaments on each side in a mass ; others do this after invert- 
ing the uterus into the vagina ; others bisect the organ and remove it in 
two halves. The French and Belgian surgeons have been obtaining the 
most brilliant results by the use of pressure forceps applied up each side 
of the uterus, left on the broad ligaments for some hours, and then care- 
fully removed. The time during which it is necessary to leave them on 
has been gradually reduced till, I believe, some operators think twelve 
hours long enough. Of course the sooner they can be removed with 
safety, so far as fear of haemorrhage is concerned, the less the risk of 



HYSTERECTOMY 633 

sloughing of the tissues crushed between their blades. This unfortunate 
result of their use, which must happen to some extent in all cases, has led 
to septicaemia in not a few. This is to me the great objection to their use. 
As I have already said, Mr. Greig-Smith, several years ago, introduced a 
very efficient little clamp for securing the broad ligaments, in which I 
ventured to make some slight modification, but I have never used it on 
the living subject, and I think if I ever do adopt this method I shall 
prefer to use some of the forceps now in use in France. E-ichelot's seem 
admirably adapted for their work, and his brilliant success bears witness 
to their excellence. 

Hysterectomy for Intractable Inversion. — It is very rarely that some 
of the excellent repositors which have been invented will not reduce 
an inverted uterus ; but now and then a case has been overlooked and left 
so long untreated that abnormally related parts have grown firmly to- 
gether, and nothing is left but to remove the organ. Formerly it was 
thought sufficient to amputate the mass with an ecraseur, and I have m}^- 
self successfully performed this operation. It is, however, a most un- 
scientific procedure, and has in several cases ended in serious disaster — 
a coil of intestines or other important organ having become involved in 
the amputation. 

Tlie diagnosis of complete inversion should not be difficult; com- 
bined examination, with aid of an anaesthetic if necessary, will soon show 
the presence or absence of the uterine body in its proper place in the 
pelvis or abdomen. The finger in the rectum will recognise the depres- 
sion in place of the uterine body ; in the vagina the absence of the os 
uteri, and possibly the detection of the openings of the Fallopian tubes, 
will render the diagnosis absolute. It may occasionally be a little diffi- 
cult at first to diagnose between inversion and a large polypus, but 
attention to the above points should prevent error. If both conditions 
should be j)resent, the polypi having led to inversion, then greater care 
may be necessary to avoid unintentionally including the uterine body in 
the operation for removal of the polypus. 

Immediate removal by cutting, with ligature of the divided vessels 
by the ecraseur or the cautery, Avere the methods formerly used, and 
with a terrible mortality. Gradual removal by compression, as may be 
supposed, was not much more successful, though the elastic ligature 
certainly reduced the mortality considerably. 

The method of first compressing the mass with an encircling ligature, 
so as to produce adhesions between the abnormally opposed serous sur- 
faces, and then amputating below the constriction, very considerably 
reduced the mortality, but it still remained over 15 per cent. There can 
be no reason why complete excision, carefully performed on the lines laid 
down for excision in procidentia, should not be attended with good 
results ; but it would be necessary to bear in mind the changed relation 
of parts brought about by the inversion, and to modify the exact details 
of the procedure accordingly. 

Operations on the Gravid Uterus. — I now pass to the consideration 



634 SYSTEM OF GYNECOLOGY 

of the various operations which, have been suggested for dealing with the 
gravid uterus, when the natural passages, either from deformity of the 
bones of the pelvis, or from the presence of a neoplasm, do not admit of 
the delivery of a living child. 

I think it is beyond the scope of my article to deal with symphysiotomy, 
pelviotomy, smdpubiotomy. The cases in which these methods would be 
employed must be very unusual, when we have such a range of successful 
procedures as the improved Csesarean section, Porro's operation, and 
complete extirpation to choose from. 

Regional Anatomy of the Pelvis at Term. — Polk and Greig-Smith, by 
their careful dissections, have thrown valuable light upon the changes 
brought about in the regional anatomy of the pelvis by pregnancy, espe- 
cially in the relations of the peritoneum, the ovarian and the uterine ar- 
teries, the uterine ligaments, and the ureters. 

Briefly these changes are, elevation of the pelvic peritoneum, with 
great laxity of the underlying cellular tissue ; the broad ligaments be- 
come abdominal instead of pelvic, and triangular in form instead of quad- 
rangular ; their layers are separated and more loosely attached. The 
arteries are much enlarged, especially the ovarian ; the uterine artery is 
elevated so that it is in part removed from the uterine wall ; its relations 
to the ureter remain much the same. The ureters are elevated along 
with the bladder and vagina, and lie very close to the latter along its 
antero-lateral surfaces. At the end of the first stage of labour the ureter 
crosses the line of the os uteri obliquely at the juncture of the anterior 
and middle third ; and, at the level of the external os, the space between 
the ureter and rectum is twice as great as the space between the ureter 
and bladder. 

CcBsarean section would, I suppose, hardly come under hysterectomy 
and allied operations ; but as it is one of the steps in the other two 
operations, I shall briefly consider its performance. 

The terrible mortality of the old Csesarean section led to the equally 
sad destruction of infant life by craniotomy and other barbarous proceed- 
ings ; but now with the splendid achievements of abdominal surgery all 
these horrors are passing away, and we have only to consider which 
surgical procedure is most suitable to the particular case, and how best 
so to perfect the procedure as to save the lives of the largest number 
of mothers and children. The surgeon who decides upon performing 
Csesarean section should always be prepared with the instruments 
necessary for proceeding to Porro, or to complete hysterectomy; if 
circumstances arise which render either of these procedures necessary. 

The improved Ccesarean section owes its present success chiefly to the 
German surgeons, especially to Sanger and Leopold. The former first 
suggested the improved method of suturing the uterus, and the latter 
was the first surgeon to carry it out successfully. Many small details 
which contribute to success, and require care, will be duly noted in 
describing the operation ; but the detail which has brought about such 
an astonishinc{ difference in results between the old and the new Caesarean 



HYSTERECTOMY 635 



section is the method of closing the uterine wound. Another most 
important element in the recent success is the performance of the opera- 
tion at an appointed and carefully selected time — not during the first 
stage of labour, but, as in any other abdominal operation, after due and 
careful examination and consideration of all the conditions, and, more 
important still, after due and careful preparation of the patient. Thus 
everything is carried out in order and without hurry or excitement, 
conditions which so frequently brought disaster in the old operation. 
Another great advantage of the " elective operation " is that it need no 
longer be performed by the inexperienced family doctor, but by the trained 
and experienced abdominal surgeon; and I maintain that there is no 
great operation of surgery which so clearly demands that its performance 
should be placed in the hands of the experienced operator. When it was 
thought not advisable to operate until labour had commenced, such an 
arrangement was often impossible, but now the patient can be carefully 
prepared and placed in some apartment suitable for operation ; she should 
also have the benefit of skilled surgery. The preparation of the patient 
should be precisely the same as for any other abdominal operation ; the 
vagina and external genitals should be carefully cleansed some days 
beforehand. Then, just before the operation, the surgeon should exam- 
ine the cervix, and satisfy himself that it is patent, and will allow of 
proper vaginal drainage, and also examine the uterus and see that it 
contracts properly. 

Operation. — The abdominal incision should be from 5 to 6 inches 
long. It should commence above and to the left of the navel, and be 
carried down only to a point about 2\ inches above the pubes — the 
elevation of the peritoneum between the uterus and bladder will place 
the latter organ in danger if it be carried lower. As soon as the uterus 
is exposed, the assistant standing opposite to the operator should place 
his hands deep in the flanks and under the uterus on each side, so that 
he can press it forward into the incision, making it slightly bulge through 
it. Then a large flat sponge is placed between the uterus and the anterior 
parietes on each side. If the assistant attends quietly and carefully to 
his work all through the operation, always keeping the uterus well pressed 
up against the anterior parietal peritoneum, no fouling of the peritoneum 
is possible ; but if I had to perform the operation without an assistant 
upon whom I could rely for this help, I should substitute the long in- 
cision, and turn the uterus out of the abdomen before incising it. 

The incision into the uterine wall is made vertically, beginning well 
up at the top of the abdominal incision, and not carried too low, for fear 
of wounding branches of the uterine artery. 

If the haemorrhage be very severe, a few pairs of my T-shaped forceps 
may be rapidly applied to the edges of the cut, but if the use of forceps 
can be avoided it is better, as all traumatism is bad. The operator then 
seizes the child by the head and rapidly extracts it. Should the feet 
present he may extract by them ; but in this case care is required lest 
the uterine wound close tightly round the child's neck. If this should 



636 SYSTEM OF GYNECOLOGY 

happen it must be freed at once by enlarging the wound in an upward 
direction, lest it be torn down into the lower segment of the uterus. 
The cord should then be rapidly divided between two pairs of forceps, or 
two ligatures which can be almost as quickly applied, and the child 
handed to an assistant or nurse. A hypodermic injection of ergotine 
should then be given, and, if the mother's condition allow it, a short 
pause be made to allow of natural separation of the placenta. If this 
do not occur, and blood is being lost, the placenta must be peeled off and 
extracted, the uterine cavity thoroughly cleared of the secundines, and 
a strip of iodoform gauze passed through the cervix to act as a drain. 

Closure of the Uterine Wound. — The all-important step in the opera- 
tion has now to be carried out, and the uterine wound closed by Sanger's 
suture. First a row of deep silk sutures (No. 2 Chinese twist) is placed ; 
each suture enters the peritoneum about half an inch from the edge of 
the wound, slants obliquely through, and is brought out in the muscular 
wall some little distance from the uterine cavity. These sutures are 
three-quarters of an inch apart, and the uppermost and lowermost ones 
should be placed well beyond the limits of the incision ; then a second 
row is placed, two sutures between each of the deep ones, the needle enters 
the peritoneum a little nearer its cat edge than for the previous ones, and 
comes out more superficially in the uterine wall ; then it is carried up 
and through the cut edge of the peritoneum on its own side, then through 
the cut edge of the peritoneum opposite side of the incision, and through 
the cut edge of the uterine wall about its centre, and out obliquely 
through the peritoneum ; this row of sutures is also carried beyond the 
snds of the incision. When all are in place the superficial ones are tied 
first, and these will invert both edges of peritoneum ; then the deep ones 
are tied, and these bring the serous surfaces firmly together, almost bury- 
ing the superficial sutures. Should the apposition of the serous surfaces 
still not appear close enough all along the line, a fine continuous super- 
ficial suture may be applied to make everything still more secure. The 
essence of the method is not to let any of the sutures come near the in- 
terior of the uterus, and to bring two good broad strips of inverted 
peritoneum firmly into contact all the way along the incision. If the 
assistant has done his work well by keeping the uterus well against the 
parietes there will be no need to sponge out the peritoneum ; all that 
is necessary will be to remove the flat sponges, and close the external 
incision. 

If it be desirable to prevent the possibility of future pregnancies, the 
tubes on each side should be ligatured in two places with fine silk, and a 
small V-shaped portion removed. 

If any drainage is desired a small rubber tube may be placed in the 
anterior cul-de-sac, and sutured into the lower angle of the abdominal 
wound. 

If the uterus contracts properly the case will probably do well, often 
as well as after an ordinary confinement; but if, before the abdominal 
incision is closed, the uterus is seen not to be contracting properly, then 



HYSTERECTOMY 637 



it may become a question whether it is not better to perform Porro's 
operation, or a complete extirpation of the uterus immediately. 

The literature of the subject of Caesarean section is now so very 
large, that I have avoided going into the history of the operation, or 
attempting to deal with the suggestions good, bad, and indifferent, which 
have been made concerning its method of performance ; I have contented 
myself with describing, as clearly as I can with our present knowledge, 
the way in which I think it should be performed. 

The only point which perhaps deserves notice to which I have not 
alluded, is the question of applying temporary intraperitoneal elastic 
compression round the uterus, at the level of the internal os, during the 
incision of the uterus and the extraction of the child. I do not think it 
is necessary in ordinary cases, but if alarming haemorrhage occur a loop 
of elastic tube can be rapidly passed round and tightened, and its 
crossed ends secured in a pair of Wells' large pressure forceps. The 
objections to its use are that it adds another element of risk in the 
traumatism produced at its site, and, if the operation be at all prolonged, 
that it asphyxiates the child. I think, however, it may be worth while 
always to place a rubber tube in position round the neck of the uterus 
before incising it, so that if necessity arise it can be quickly tightened. 
If it has to be applied at an urgent moment valuable time will be lost, 
and the peritoneum will be fouled with blood, and very likely with 
uterine contents also. 

The after treatment is the same as for any other abdominal opera- 
tion, with the addition of attention to the condition of the mammae, and 
warm antiseptic vaginal douches every six or eight hours. The cervical 
drain will in most cases gradually come away by itself ; but if it do not, 
it can be gently withdrawn in about forty-eight hours. 

Porro's operation, first planned and successfully performed in 1876 
by the Italian surgeon whose name it bears, was suggested to him by 
the success of extraperitoneal supravaginal hysterectomy, and is a com- 
bination of Caesarean section with this latter operation. Some 250 cases 
of this operation have now been recorded, with a maternal mortality 
of about 50 per cent. Utero-ovarian amputations performed during 
pregnancy, but before the foetus is viable, have also been spoken of, 
improperly, as Porro's. 

One of the advantages claimed originally by Porro for the operation 
was that it would save more mothers than Caesarean section ; probably 
this was true then, with the old Caesarean section in vogue ; but with 
the improved and " elective " Caesarean section I doubt if the claim still 
holds good. 

Another great advantage claimed was that the operator could select 
his own time, and properly prepare the patient ; this advantage now 
belongs likewise to Caesarean section. 

The patient should be prepared in exactly the same way as before 
hysterectomy for tumour ; that is, the bowels should be well cleared, the 
bladder emptied, and the vagina and vulva well cleansed by antiseptic 



638 SYSTEM OF GYNECOLOGY 

douclie, washing, and shaving. Any time near the time of natural 
delivery will suit quite well for the operation, which, up to the time of 
full exposure of the pregnant uterus, is performed in exactly the same 
way as for tumour. When this point is reached the site of the placenta 
should, if possible, be made out in order that this organ may be avoided 
in opening into the uterus ; this discovery is, however, rarely possible, 
and more stress has been laid on its importance than I think it deserves. 
A trustworthy assistant should then grasp the uterus and broad ligaments 
at the lowest point which he can reach with his hand in the pelvis, so as 
to be ready at once to arrest the circulation when the uterus is opened ; 
but he should not interfere by closing his hand until the operator is 
actually beginning to incise the uterine wall ; thus the child's blood- 
supply is not interfered with till the last moment. A rubber tube 
may also be put loosely round the cervix, as advised in the previous 
operation, to be secured if necessary. The operator, avoiding the 
placental site, if this be possible, makes a small incision through the 
uterine wall and then completes the opening by tearing with his fingers 
(a modification originally suggested by myself when assisting Dr. Godson 
to perform the operation) ; the child is then at once extracted and handed 
to an assistant, who ties and divides the cord, and gives the necessary 
attention to the child. The uterus should be packed round with carbolised 
sponges during incision and removal of the child ; and when the latter 
part of the procedure is accomplished, the opening into the uterus should 
be plugged at once with a large sponge or sponges, the surrounding 
sponges quickly removed, and Koeberle's serre-noeud applied round the 
base of the uterus and the broad ligaments, just above the hand of the 
assistant, who has been preventing haemorrhage by firmly grasping it as 
already mentioned. If it be thought advisable to leave one ovary, it can 
readily be excluded from the wire at this stage, either with or without 
its tube ; and this I strongly advise in all cases in which the woman 
operated upon is married and young. As soon as the wire is fixed and 
screwed up the assistant withdraws his hand, the pin is passed through 
the uterus immediately above the wire, and the uterus is cut away, great 
care being taken to pack it well round again with carbolised sponges, and 
to prevent any escape of its contents into the peritoneum. If there 
appear to be any necessity for draining the peritoneum, a Keith's glass 
tube is placed in the pouch of Douglas, as soon as the peritoneum has 
been sponged out, and the wound closed round it by the usual silk 
sutures ; drainage is, however, rarely necessary in these cases, and is to 
be avoided if possible, for the reasons already given in describing the 
operation as performed for fibromyoma. Dry gauze dressing is packed 
round the stump, which is then carefully treated with solid perchloride 
of iron ; more gauze, held by big, broad, supporting bands of adhesive 
plaster and covered by a towel pad, and an abdominal binder secured 
by three safety pins, complete the procedure. The after treatment is 
precisely the same as after the operations already described, except in 
so far as it may be modified by any degree of milk fever. A free and 



HYS TERE CTOM V 639 



early application of extract of belladonna and glycerine covered with, 
cotton wool and oil silk, repeated every twelve hours, is the most effi- 
cient and soothing remedy for painful swelling and hardness of the 
breasts, a remedy far more efficacious than the evaporating lotions often 
recommended. The operation described above was suggested by Caval- 
lini, by Michaelis, and by Blundell, and actually performed by Storer of 
Boston in 1869 to stop a serious haemorrhage during the performance of 
Csesarean section. 

Mliller suggested a modification which may be advantageous when 
the operator has no reliable assistant to grasp the uterus. He makes a 
long incision, turns the uterus out entire, and surrounds its base with an 
elastic ligature which is tightened before the uterus is opened. This 
procedure and the opening into the uterus must be very rapidly done, 
however, if the child is to be rescued from asphyxia. The method is 
specially recommended in order to avoid fouling of the peritoneum, but 
this accident can be easily avoided with proper sponge packing. 

Combined Coesarean Section and Complete Hysterectomy. — In certain 
cases it may be thought advisable to complete a Caesarean section by the 
complete extirpation of the uterus and its appendages ; it is not neces- 
sary to give any special description of this procedure, as the first part 
is merely Csesarean section up to the extraction of the child, and the 
second part is complete abdominal extirpation (hysterectomy) already 
fully described. 

It only remains for me to describe the after treatment of a patient who 
has been subjected to any form of hysterectomy, and to give a list of the 
instruments and dressings which should be provided for the operation. 

After Treatment. — The after treatment is the same after all forms of 
hysterectomy, for whatever disease performed ; and after removal of the 
appendages. The patient is kept on her back with, the knees over a 
good firm pillow, and the head and shoulders well supported by an 
inclined plane of pillows. I never let the patient move from this position 
till the end of a fortnight, when she is in many cases ready to get up ; 
though the separation of the stump in an extraperitoneal hysterectomy 
may keep a patient on her back for a much longer time. Nothing but 
an occasional sip of warm water (ice dries the tongue and creates more 
thirst) is given by the mouth until all sickness, if any there be, is over ; 
and, more important still, till the flatus passes down by the anus : then a 
little weak tea with plenty of milk, equal parts of milk and hot water, 
milk and soda water, some of the meat essences, pure clear beef tea, or 
mutton or chicken broth, may be taken ; about the third or fourth day a 
little boiled fish, or sweetbread, is ordered, and so gradually an ordinary 
diet is reached. 

Rectal Feeding. — All my patients are fed by the rectum, every three 
hours, from the time they are conscious after the operation, till they are 
taking sufficient nourishment by the mouth; and clear jelly beef tea 
made as strong as it can be made without salt; is the only thing used for 
these injections. 



640 SYSTEM OF GYNECOLOGY 

Opium. — In this injection twenty drops of laudanum are given every 
six hours, unless I see some reason to omit them ; for I am still convinced 
that the majority of cases do better, and are more comfortable during 
the first few days, with laudanum than without it. I rarely continue 
its use beyond the third or fourth day. Any medicine, that it may be 
necessary to give, is administered also in the injections. If the injections 
are not well absorbed and the refuse is offensive, the rectum is washed 
out with half a pint of warm water and rested for half an hour. Two 
to five grains of quinine mixed with a tablespoonful of port wine are then 
added to each injection; this destroys septic elements, and the rectum 
will soon absorb well again. I have seen a patient at death's door from 
septicaemia, brought on by injudicious rectal feeding, and allowing a lot 
of decomposing stuff to remain in the rectum. The vaginal pipe of a 
Higginson's syringe should always be passed into the rectum ten minutes 
before an injection is given, to allow the wind to pass, and to let any 
fluid escape, a little soap dish or a towel being placed under its open 
end to absorb the latter. If the rectum be irritable it is a good plan to 
wash it out with half a pint of warm water, or with the same quantity of 
a solution of borax, or boracic acid, to allow it to rest for half an hour, 
and then begin the injection again. Sickness or retching I treat by 
large doses of hot water ; sometimes a teaspoonful of sal volatile in a 
tumbler of hot water acts as an excellent quick emetic, and is also a 
little stimulating. Chloroform sickness is allayed by 15-grain doses of 
oxalate of cerium in mucilage repeated every three hours. Sometimes 
when the flatus does not pass, and green sickness is troublesome, a dose 
or two of white mixture, not repeated often enough or given in large 
enough dose to act as an aperient, acts like a charm. I give for a dose 
a drachm of sulphate of magnesia, with a scruple of the carbonate, and 
a little spirit of chloroform in an ounce of peppermint water. 

Drainage. — If a drainage tube be used the wound is dressed night 
and morning, the sponges in the india-rubber sheet washed and re- 
carbolised, and the fluid in the glass tube carefully sucked out with an 
india-rubber tube attached to the nozzle of a glass syringe ; the rubber 
tube should have a round hole cut in its side, near the end which goes to 
the bottom of the glass tube, or it will suck against the pelvic peritoneum 
and not act properly. It is well also at each dressing to lift the glass 
tube a little, and to turn it round in the wound ; as little bits of fat, or 
omentum, or even the wall of the gut, may be drawn into its side holes 
and get strangulated there, causing great difficulty in its subsequent 
extraction. When there is no longer anything in the sponges, and only 
a little clear serum in the tube, it is removed. If there be any doubt as 
to the exact time when it is advisable to remove it, a rubber tube may 
be slipped through it, long enough for the glass tube to be withdrawn 
over it, and the rubber one left in for another twelve or twenty-four 
hours ; so that if fluid still gathers it may escape into the dressing. The 
glass tube does in some cases irritate the peritoneum, causing a flow of 
serum, and also some trouble with flatulence ; and it may be difficult to 



HYSTERECTOMY 641 



decide whether an increased flow of serum be due to this cause or to 
septicity. 

Removal of Sutures. — In an ordinary case, where the wound is entirely 
closed, I rarely dress till the fifth or sixth day ; I then remove half the 
sutures; on dressing again in three or four days I remove the rest, 
strapping up carefully after each dressing with strong broad straps of 
adhesive plaster, which is much better than any soft form of roller 
bandage, as the firm support of the plaster does not allow the intestines 
to become distended with gas. In extraperitoneal hysterectomy cases, I 
am guided as to the time for change of dressing by the presence or 
absence of any staining of the plaster, or by the necessity for tightening 
the screw ; this I often do, however, through a little window without 
disturbing the rest of the dressing. Usually the hysterectomy cases are 
dressed about the fourth or fifth day, and then every third day till the 
stump begins to separate ; then I dress every day or every other day, 
thoroughly dusting everything, as I raise the old dressings, with a little 
pepper dredger full of finely powdered boracic acid. If this be done the 
stump will separate without smell, which is a great comfort to the patient, 
if it be not also a safeguard. I generally leave in the sutures, or some of 
them at any rate, longer in these cases, as the wounds are very liable to 
reopen if the sutures are taken out too soon. Whether this tendency be 
due to the nearness of septic material in the stump, or to the mechanical 
wedge-like action of the latter, I cannot say : I think both agencies play 
their part. It is worthy of note that patients operated upon during 
pregnancy are specially liable to this accident. Careful strapping of the 
wound for a considerable time after extraperitoneal hysterectomy is ad- 
visable, to try to prevent the occurrence of hernia at the point where 
the stump is fixed ; this accident is of such common occurrence that, to 
my mind, it is the greatest objection to this method of operating. These 
patients should be specially cautioned not to expose themselves to any 
risk of stretching the scar, until the changes from soft elastic new tissue 
to firm, fibrous, old scar tissue have had time to occur. I always order 
all my patients to wear a good supporting abdominal belt ; and I do not 
let them leave it off till I have examined the scar, and seen that it is firm 
and linear. I do not in the least believe in the allegation that support 
weakens the muscles and tends to produce hernia. A little practical 
observation in a matter of this kind is worth bushels of opinions, and I 
notice that patients who leave off their belts too soon are very liable to 
hernia. 

Instruments and Dressings. — The following are the instruments and 
dressings which I provide for an operation, whether it be a simple re- 
moval of the appendages, or a difficult hysterectomy : — 

About twenty-five Turkey cup sponges of varying size, and one large 
flat ditto. I vary the number from time to time, so that the nurses 
should really have to count, and not get careless in this most important 
detail. They are well cleaned in washing soda and water, and after 
repeated rinsing to get rid of the soda, are placed in 1-20 carbolic lotion, 

2t 



642 SYSTEM OF GYNMCOLOGY 

whicii, just before the operation commences, is turned into 1^0 lotion 
by the addition of an equal measured quantity of hot water. If the 
sponges are thoroughly damp and clean, I believe a very few minutes' 
soaking in 1-20 is quite sufiicient to render them safe, and surgically pure. 

A thin mackintosh sheet, large enough to cover the chest and abdo- 
men, and to hang well over the sides of the table, with an oval hole cut 
in it from 4 to 8 inches long, and 3 inches broad ; the edges of the hole 
being surrounded with an inch broad layer of carbolised adhesive plaster. 

A yard of strong adhesive plaster, cut into strips of varying width 
and length, suitable to the particular case. 

A binder made of fine flannel, lined with old calico turned well over 
the edges of the flannel, so that when the binder is applied the flannel 
does not anywhere touch the skin. 

Some good strong safety pins of the old-fashioned kind, without any 
cap or contrivance for harbouring dirt. 

A couple of packets of carbolised gauze. 

One lb. of carbolic acid or absolute phenol, made into twenty pints of 
lotion just before the operation, so that it is hot and ready for use. An 
excellent vessel in which to make this lotion is an earthenware or china 
slop jar, obtainable now in most houses ; they just hold twenty pints of 
fluid. The lotion should be made by dissolving the acid in really boiling 
water, and then making up the quantity with ordinary hot water. 

A small bottle of laudanum for the nurse's use after the operation. 

A bottle of glycerine to take the carbolic acid out of my own hands 
after the operation. 

A small bottle of tincture of iodine. 

A wide-mouthed bottle of solid perchloride of iron. 

A box of bistouries ; a Key's director ; a long straight needle with a 
large eye ; an Adam's eye hook for picking up the peritoneum ; a pair of 
catch forceps for pulling out the tongue ; two dozen straight needles 
about 2\ inches long, threaded in pairs with No. 2 carbolised Chinese 
twist, and arranged in a piece of gauze. 

For a hysterectomy, two pairs should be threaded with No. 3 silk for 
use above and below the pedicle. 

Two or three curved, long-handled, perineum needles, armed with a 
long thread of silk — No. 3 for final tying, and No. 4 for temporary use. 

Three or four skeins of carbolised Chinese twist wound on glass 
reels, Nos. 1, 2, 3, and 4. 

At least two dozen pairs of Wells' pressure forceps, some curved, some 
straight ; in a big enucleation hysterectomy more will often be required. 
A few pairs of my own square-ended forceps. From four to six of Wells' 
long and strong pressure forceps, some straight, some Curved. A couple 
of long, narrow-bladed, temporary clamps. A pair of scissors curved on 
the flat. A scissors handled needle holder. 

Two or three of Koeberle's serre-noeuds, and a good supply of soft 
iron wires of various lengths and thicknesses, with one end looped ready 
for use. The soft iron wire is much to be preferred to the new amalgam. 



MALIGNANT DISEASES OF THE UTERUS 643 

whicli is very liable to yield, and allow subsequent oozing. A pair of 
pliers for tightening the wire and cutting it. A strong, flatheaded cork- 
screw with loop handle. Some of my pedicle pins with screw cap. A 
pair of oval-ended, long-handled polypus forceps, with catch on handles, to 
be used for introducing the sponges into the pelvis. A fine long trocar 
and canula suitable for exploratory puncture. An assorted series of 
Keith's glass drainage tubes, a rubber sheet for use with tube, a glass 
syringe armed with a fine piece of red rubber tube for sucking out con- 
tents of glass tube. Some rubber tubing of various sizes suitable for 
drainage, or to use as a temporary elastic ligature. Uterine and bladder 
sounds. 

J. Knowsley Thorxton. 



MALIGNANT DISEASES OF THE UTEEUS 

Introductory. — The task of setting forth the present state of our 
theoretical knowledge and of our practical methods of dealing with 
malignant disease of the uterus does not include the consideration of the 
pathology of cancer in general. We have, however, suificient material 
for a more definite and partial treatment of the subject. 

Malignant disease, as met with in the female sexual organs, presents 
certain anatomical naked-eye changes of tissue and a conformation of 
neoplasms which is peculiar to these parts, but, whatever their clinical 
importance, they are of comparatively little pathological significance. 
But there are other considerations — such as frequency of occurrence, 
causation, and surgical and medical methods of treatment — which are 
highly important, and which require special exposition on account of 
the anatomical structure of the parts, the relations of the affected organ 
to pelvic and other viscera, and its peculiar physiological functions. 

The pathology is also to a large extent special on account of the minute 
anatomy of the parts affected, the relations of their constituent elements 
to the origin of the malignant process, the methods of invasion, and the 
extent of the changes produced by the growth of the neoplasm. For an 
exposition of the present state of the science of bacteriology in relation 
to malignant disease the reader is referred to System of Medicine, vol. i. 
We have to consider the practice of medicine as well as pathology ; 
and the two subjects are not always so mutually helpful and comple- 
mentary as might have been expected. Some of the pathologists who 
have given special attention to this subject may be, perhaps, too prone to 
attach undue importance to their methods of investigation, to multiply 
non-essential details, and to magnify unimportant differences, which ob- 
scure the view in the direction of general conclusions. They naturally 
become absorbed in the contemplation of the specimens which are to 



644 SYSTEM OF GYNECOLOGY 

them the subject material for observation and reflection; they are not 
concerned with the aspects of disease and its human interest. The 
clinician, on the other hand, has ever with him the human interest of 
the disease, and he looks sometimes impatiently towards the pathologist 
for practical guidance in dealing with the individual case. It is to him 
of small interest what name the nomenclature of the decade assigns to 
a certain conformation of epithelial or connective tissue elements. He 
wishes to know whether the disease in question is malignant or benign ; 
and he may occasionally be harsh and unjust in his judgments of scien- 
tific pathology when the answers are not so prompt and lucid as he 
may have expected. 

In the exposition of malignant disease of the uterus within reason- 
able limits, considering the inherent difficulties and the present state of 
our definitely acquired knowledge, I can only, to the best of my judg- 
ment, assign the space which I think suitable to each part of the subject; 
hoping for the early advent of the time when pathology and practical 
gynaecology will be more helpful to each other than they are now, and 
the material for their exposition may be more complete and homogeneous. 
If I err on one side the pathologist may think my work incomplete and 
unsatisfactory, perhaps puerile and shallow ; if I err on the other side, 
the gynaecologist may consider the result tedious and unintelligible, 
perhaps pretentious, certainly unpractical. 

Cancer of the uterus, as popularly understood, implies the existence 
of a growth or tumour whose most striking characteristics are — the ten- 
dency to spread by sending out roots in all directions from the point of 
origin, so as gradually to destroy the womb itself ; and in the process to 
produce such symptoms as intense pain and foul discharges, distressing 
to the patient and those about her, and finally to cause a lingering 
and miserable death. The popular notion of pain as an essential 
symptom in such a terrible malady interposes one of the principal diffi- 
culties in the way of seeing the cases in the earlier stages of the disease, 
and of applying the most efficient treatment. 

Another popular notion, which I fear is also held in some vague and 
uncertain way by many members of the medical profession, is that the 
menopause is associated with irregular and profuse haemorrhage from 
the uterus, and even with other discharges from the uterus or pudenda. 
This widely-accepted theory of a final " cleansing," as a disagreeable 
episode necessitating patient waiting for its termination, is one of the 
principal reasons why long delay so often occurs before women affected 
with cancer of the uterus seek professional advice ; and it is to be feared 
that it sometimes accounts for the fact that the advice obtained is not 
always based on precise diagnosis, followed by prompt and effective 
treatment. 

In order to formulate our knowledge, to facilitate the description of 
symptoms, and to indicate the sequence and relations of processes and 
phenomena, it is necessary for us to classify the most striking forms 
which malignant diseases of the uterus assume. We must constantly 



MALIGNANT DISEASES OF THE UTERUS 645 

keep in mind, however, that these classifications apply with any preci- 
sion only to the comparatively early stages of the disease ; and we must 
also remember that the terms which we employ only indicate the pres- 
ence of pathological tendencies producing certain tissue changes. The 
ultimate facts determining their origin and their relationships are still 
unknown to us. The malignant diseases that we call epithelioma, car- 
cinoma, and sarcoma, may all be present in the same individual. This 
co-existence of disease in the various forms implies, so far as we know, 
no more than a greater measure of some condition of the general health 
determining degenerations of which our exact knowledge is so limited 
that controversy can hardly be said to have begun ; but it would seem 
to suggest that the various tumour forms assumed by tissues under the 
malignant process do not differ so essentially as we are apt to believe 
when we look at them too narrowly on the histological side. 

With regard to the most common early forms of malignant disease, 
epithelioma and carcinoma, much has been written in recent years; 
but there is little that can be called new in the recent literature of the 
pathology, whereas enormous advances have been made during the 
same time in the therapeutics, especially surgical, of malignant dis- 
eases of the uterus. Perhaps, from the pathological point of view, the 
most important question at the present time is the position of adenoma. 
Within the last few years much has been added to the literature of this 
subject, and although there is considerable difference of opinion, the 
tendency at the present time appears to be to recognise its compara- 
tively frequent occurrence in a malignant form, and to place it in a 
separate category from carcinoma. 

The most recent of all questions with regard to the malignant diseases 
of the uterus is the character and seat of origin of '• deciduoma malignum." 
The subject is comparatively of little importance from the practical stand- 
point, because of the rare occurrence of cases ; but from the point of view 
of the pathologist few subjects could be more interesting. There can be 
little doubt that the extraordinary amount of attention which this subject 
has received, is bound to bring about not only a considerable increase in 
our knowledge of the changes, both normal and pathological, which occur 
in the postpartum uterus, but also to add to our knowledge of the devel- 
opment, the normal physiology, and the pathology of the placenta. 

In the following pages the names epithelioma, carcinoma, and sar- 
coma are used in the ordinarily accepted sense — the two former indi- 
cating a malignant new growth of epithelial origin, the last implying a 
malignant neoplasm of connective tissue origin. Other names, such as 
" adenoma malignum " and " deciduoma malignum," may be accepted 
provisionally as implying certain characteristics to be discussed in deal- 
ing with them in their proper place. Whether they should be retained 
in our nomenclature is a question which can be settled only when dis- 
cussion and observation have produced something like unanimity of 
opinion concerning the origin and structure of the tumours, and the 
course and symptoms of the ailments resulting from their growth. 



646 SYSTEM OF GYNECOLOGY 

The classification of the malignant diseases of the uterus which will 
be adopted here as most suitable to the present state of our knowledge, 
and as most convenient for exposition, is the following : — I. Epithe- 
lioma et carcinoma portionis vaginalis uteri; II. Carcinoma cervicis 
uteri ; III. Carcinoma corporis uteri ; lY. Sarcoma corporis et cervicis 
uteri ; V. Adenoma malignum (corporis et cervicis uteri) ; VI. Decidu- 
oma malignum. The varieties or subdivisions of each form will be 
described and discussed in their proper places. 

I. Cancer of the Vaginal Portion of the Uterus. — Patliological 
Anatomy. — The pathological anatomy of cancer of the vaginal por- 
tion and cervix forms a very difficult and extensive chapter in any 
exposition of malignant disease of the uterus. The mass of pub- 
lished observations, both clinical and histological, is so enormous, and 
the views of pathologists who have devoted much attention to the 
subject are so diverse and even contradictory, that at first sight it is 
difficult to detect any sort of order in the chaos. When we remember, 
too, the great amount of controversy which has taken place on almost 
every detail of published observation, and the impossibility for each 
author or expositor, for the time being, absolutely to divest himself 
of some preconceived opinion or bias, we may readily conclude that the 
easiest, and perhaps the best course is to rest satisfied with endeavour- 
ing to record concisely the state of knowledge and opinion at the time 
of writing. 

The vast mass of observation and opinion previously on record has 
been greatly increased within recent years, when the bulk of the pro- 
fession in Europe and America has declared so steadily in favour of 
extirpation in the treatment of malignant disease of the uterus. Not only 
has exact clinical and macroscopic observation become more confident, 
exact, and practically useful, but the material obtained for the histologist 
and pathologist in comparatively early stages of the disease by operation 
and post-mortem examination, has become vastly more various and 
interesting, as well as incomparably greater in amount. To the same 
cause also we owe the fact, all important for the practical application 
of the pathological knowledge acquired, that clinical observation and 
histological investigation have become more closely associated. As an 
illustration of the industry with which observations are made and 
published, it may be mentioned that the last three volumes of the 
JahresbericJit ilher die Fortschritte aufdem Gebiete der Gehurtshillfe und 
Oynllkologie, ending with 1894, contains references to 528 contributions on 
the malignant diseases of the female sexual organs alone. We may ask 
whether progress in the acquisition of exact knowledge of the pathology 
of uterine cancer has been great in proportion to the facility of obtaining 
material and associating the observations with the history of individual 
cases ; and whether the progress of pathological knowledge has corre- 
sponded with greater precision of diagnosis and treatment by the prac- 
tical gynaecologist ? On this point, it must be confessed, there is much 



MALIGNANT DISEASES OF THE UTERUS 647 

reason to answer with hesitation. Even the most recent text-books or 
manuals of gynsecology show strongly the influence of authority in their 
pathology, for their authors, after critical analysis of the statements and 
opinions expressed in the reports of the earlier observations, implicitly 
admit that they must accept them as final and complete. And yet 
there is a good deal in what appears as description of personal observa- 
tions which must have contained an important element of inference ; and 
it may be alleged without undue rashness that some conclusions offered 
by the pathologists, and given practical effect to by the gynaecologists, 
have not been justified by the exact clinical observations of recent years. 
We may safely assert that the expectations founded by practical men upon 
the earlier investigations into the origin of cancer of the cervix have 
been doomed to disappointment; that no light has been thrown by 
the labours of the pathologists upon the etiology of cancer of the cer- 
vix, and that little guidance has been obtained in the treatment of the 
disease. Still we have hope for the future, and all careful observations, 
however remote from obvious practical ends, must be welcomed and 
studied. Any statement, however concise, of the views of the inquirers 
into the histology of early cancer which may be assumed to be necessary 
to completeness in the exposition of the subject, can hardly be made clear 
and independently readable without a short summary of the normal 
minute anatomy of the parts. 

For the present purpose we must keep in mind that the cervix uteri 
consists of (i.) a vaginal portion, and (ii.) a supravaginal portion extend- 
ing to the isthmus, where it joins the corpus uteri. The vaginal portion 
projects as a dome or truncated cone from the vaginal vault, and is, when 
normal, firm and resistant to the touch, and perfectly smooth, hence the 
terms os tinccE or museau de tanche. On visual inspection the nulliparous 
vaginal portion is found in health to be of a pale pink colour ; and the 
appearance of its surface confirms the impression of smoothness given to 
the sense of touch. It is planted, as it were, in the centre of the vagina, 
and around it there is an indefinite boundary, where the smooth mucous 
covering of the vaginal portion gives way to the rougher and harder 
vaginal lining. The existence of this boundary is, I believe, a point of 
some interest and importance in the spread of epithelioma of the vaginal 
portion. The os externum, or opening of the cervical canal, is the most 
striking feature presented by the vaginal portion. In the perfectly 
normal nulliparous uterus it may be oval or round ; its edges are indicated 
by the deeper colour of the margin of the cervical mucous lining, which 
generally can be more or less distinctly seen ; and it is situated rather 
behind than at the centre of the most prominent spot, because of the 
slightly greater bulk of the anterior lip. The parous or multiparous os 
externum, when the uterus is in a state of complete involution, may vary 
considerably within the limits of health. It is seldom free from marks 
of injury: there are fissures, more or less deep; retention cysts, some 
of which may have ruptured, give rise to the appearance of small 
ulcerations ; others may have dried or shrivelled up, producing minute 



648 SYSTEM OF GYNECOLOGY 

white specks on or just within the apparent margin of the cervical canal. 
The area of exposure of the red cervical lining is invariably larger in 
appearance than in the nullipara, chiefly because the os is more open. 
Deeper fissures or lacerations producing lobulation of the vaginal portion 
with ectropium, hypersecretion, induration with prominent retention 
cysts, increase in volume, and other related changes, should be looked 
upon as pathological conditions. Between this higher limit of deeper 
coloured lining about the os, and that lower limit where the smooth and 
soft mucosa shades off into the comparatively hard and rugated vagina, 
the portio vaginalis has been aptly described by Sir John Williams " as a 
cup of stratified epithelium, resembling a tailor's thimble, which fits on 
the lower end of the cervix proper." The layers of epidermis in health 
conceal the vascular papillae; but the presence of these is obvious to 
the naked eye in the early stage of catarrh of the portio, by the 
scarlatinal appearance of the reddened mucosa from which the epider- 
mis has been partially shed. In health this mucous covering can be 
felt to glide over the firm muscular mass of the cervix underlying it ; 
and in some diseased conditions it can be readily peeled off, like wet 
paper, so as to expose the chorion with its torn and bleeding papillary 
vessels underneath. 

Between the vaginal portion with its squamous epithelium, and the 
true cervical mucous membrane with its cylindrical epithelium and in- 
numerable gland structures, there is a narrow band where the epithelium 
is transitional, chiefly of a cubical form, and the glands fewer but still 
numerous. The existence of a debatable border or belt, which may in 
diseased conditions be invaded from above by glandular or papillary 
structures resembling carcinoma, or from below by the squamous epithe- 
lium of the portio, has been too readily accepted by the gynaecologists 
from the pathologists. In supjjort of the existence of this variable belt 
it is said that there is occasionally great difficulty in making out the line 
of demarcation between the portio vaginalis and cervix. This line is, 
however, almost certainly much more constant than is so often stated, 
even when on simple inspection it seems most obscured by the effects of 
exposure, of injuries, or of a catarrhal process. The cervical portion 
secretes an alkaline fluid, and the surface of the portio vaginalis is always 
moist with an acid exudation or secretion. If a piece of litmus paper be 
laid across the doubtful margin, which has been gently wiped with dry 
cotton wool, the dividing line will be always found exact and definite ; 
the moisture on the reddened surface of the apparent portio is always 
acid, that of the area of cervical lining, even when obscured by ulcerat- 
ing retention cysts or ectropium, is always alkaline. This test may 
be applied with advantage in an old laceration of the cervix with hyper- 
trophy and flattening out and erosion by contact with the vaginal wall. 
It is a guide to boundaries, and maj^ show how much has to be done 
to restore the vaginal portion by operation. With regard to the 
mucous membrane of the cervix it may be best to quote the following 
description: it "is much firmer and more fibrous than that of the body. 



MALIGNANT DISEASES OF THE UTERUS 649 

Between the rugae of the arbor vitce there are numerous saccular and 
tubular glands. In the lower part of the cervix the mucous membrane 
is beset with vascular papillae, and the epithelium is stratified, but in 
the upper half or more the epithelium is columnar and ciliated like that 
of the body. The glands, which are short, with large lumen, are every- 
where lined with columnar ciliated epithelium, even where the epithelium 
of the surface is stratified. Besides the follicular glands there are almost 
constantly to be seen the so-called ovula Nabotlii, clear yellowish vesicles 
of variable size, but visible to the naked eye, embedded in the mem- 
brane " (37). 

In describing the relevant points in the structure of the parts under 
consideration, there is one more margin or boundary which should be 
mentioned as of interest in relation to cancer of the cervix. This is the 
upper termination of the cervical canal where it is marked off by a con- 
striction, the OS internum, beyond which the cavity of the body begins. 
Just below the narrowest point at the junction of the canal of the cervix 
and of the body there is a narrow band of mucous membrane, which 
in structure more nearly resembles the mucosa of the body than that of 
the cervix. Kustner says of this border line that microscopically no 
difference can be made out between ^ cm. of the cervical mucous 
membrane and an equal measure of the corporeal lining immediately 
adjoining, either as regards the form and arrangement of glands or the 
form of the cells. Although there is no proof that this portion of the 
canal undergoes the changes in the structure of the corporeal mucosa 
which are characteristic of menstruation, its participation in corporeal 
pathological changes which do not extend to the cervix as a whole is such 
as to supply important diagnostic features ; as, for example, in catarrh 
of the corporeal endometrium, which produces a tender spot just below the 
OS internum while the rest of the endometrium of the cervix is com- 
paratively insensitive. It is just at this narrow circle of tissues in the 
transition stage between cervix and body that the malignant ulceration 
spreading from epithelioma of the cervix appears to be arrested to a ver}^ 
great extent, and when checked to extend more rapidly, and to a larger 
extent, into the muscular substance and the parametrium. 

The check to the process of ulceration at this spot, and the irregular 
hypertrophy from cell proliferation which takes its place, are probably 
the immediate causes of the pyometra which is so frequently met with 
in fairly advanced post-climacteric cases ; and the obstruction produced 
by hypertrophy must be a factor in the production of pain as a symptom 
of advancing cancer of the cervix in younger women. 

Elements of Origin of the Disease. — The discussion of the ultimate 
facts in the origin of malignant disease of the portio vaginalis and cer- 
vix uteri does not help us much either in theory or practice. The differ- 
ences of opinion amongst the pathologists are too marked to make it 
possible for those who have not specially worked at the subject to form 
an intelligent judgment ; and in practice, while there is room for fearing 
that the plausibility and symmetry of some theories have led to practical 



650 SYSTEM OF GYNECOLOGY 

applications not altogether satisfactory, tlie vast mass of detailed descrip- 
tion, and the conclusions drawn from microscopic observations by pathol- 
ogists are not so far accepted as exact and well-established as to warrant 
confident practical conclusions on the part of the gynaecologist. Most of 
the theoretic teaching, moreover, may be looked upon as merely the 
application of theories of cancer in general to the uterus in particular ; it 
is largely doctrinaire and irrelevant to practical gynaecology. 

Whether the ultimate fact be some change occurring in connective- 
tissue cells alone or in epithelial cells we do not yet know ; the decision 
may have far-reaching consequences in our methods of treatment, but 
the discussions are not yet drawing to an end. The habit of patholo- 
gists in drawing upon embryonic tissue, either persistent in some latent 
form, or reappearing in adult organs, in forming and supporting hypoth- 
eses, appears to the practical man to produce ill-defined shades of 
opinion not conducive to clearness of comprehension or to practical ends. 
It is still true, as stated by Gusserow (14), that our comprehension of 
the anatomy of malignant tumours has been greatly obscured by the 
multiplicity of observations, and by the discussions on the point of origin 
of cancerous tumours. So far as I know, Yirchow was the author of 
the theory of the connective-tissue origin of carcinoma of the cervix, and 
with the name of Waldeyer we associate the opposing view that pre- 
viously existing epithelium is the starting-point. Both theories recognise 
the epithelial character of cancerous growths, whether we call them 
carcinoma or epithelioma. Klebs supports the theory of the epithelial 
origin of malignant disease of the cervix. The transitional or cubical 
epithelium just within the os externum begins to proliferate, penetrates 
into the sbroma of the mucous membrane, and even into the underlying 
muscular tissue, and causes occlusion or destruction of blood-vessels, and 
consequent necrosis and loss of substance within the vaginal portion and 
cervix. The squamous epithelium of the portio vaginalis, especially the 
cells of the rete Malpighii, becomes the seat of papillary hypertrophy ; 
there is in the same way invasion of the subjacent structures, and 
consequent necrosis and breaking down. Thus originate the cancer- 
ous ulcers and papillary growths of the vaginal portion. With regard 
to carcinoma of the cervix, Klebs maintains that it is also of direct epi- 
thelial, not of connective-tissue origin, as was formerly believed. The 
starting-point is in the epithelium of constricted cervical glands ; and he 
assumes a tendency of the ovula Nahotlii in the vicinity of the internal os 
to undergo cancerous changes. 

Ruge and Veit, whose work has received so much attention, main- 
tain that the pavement epithelium of the portio is never the point of 
origin of epithelioma or cancer of the vaginal portion ; not even of the 
" cauliflower excrescence." The starting-point is either in the deeper 
connective tissue or in the newly formed glands found in their follicular 
and papillary " erosions." Hence the seat of origin of this cancerous 
growth is outside the os externum, and it does not extend towards the 
cervix ; its development is towards the vagina and parametrium — a con- 



MALIGNANT DISEASES OF THE UTERUS 651 

elusion carrying serious practical results. The connective tissue stroma 
becomes vascularised and passes into the embryonic condition, and the new 
cellules assume an epithelioid aspect. Exceptionally, these authors have 
seen adenomatous vegetations of glandular epithelium origin give rise to 
carcinoma ; but they never saw plugs of epithelium extending down into 
the connective tissue. So, symmetrically as it were, it is the connective 
tissue of the walls of the cervix, or of the glands of the mucous mem- 
brane, which is the point of origin of carcinoma of the cervix. They 
assert that this is the origin of a form of malignant disease of the cervix 
which does not extend downwards outside the os externum, but spreads 
all round, destroying the cervical tissues and extending readily upwards 
to the body of the uterus. 

It would be useless to multiply opinions on this subject. There is a 
certain element of controversy, as well as the record of observations in 
the literature, which has some resemblance to the discussion at present 
in progress concerning the point of origin and nature of '' Deciduoma 
malignum." But Euge and Veit's investigations and results have such a 
captivating conciseness and symmetry about them, that they were widely 
accepted, and have almost held the field ever since. Their influence on 
gynaecology was perhaps best illustrated by the work of Schroeder, who 
might almost be considered their exponent in practice ; and his influence 
is still seen in the advocacy of certain ineffective methods of surgical 
treatment of cancer of the vaginal portion. Connective-tissue origin 
suggests connective-tissue relations, hence probably the theory of early 
invasion of the parametrium by cancer of the vaginal portion, and con- 
sequent discouragement of the radical operations. 

Seat of Origin of Growth in its earliest Clinical Aspect. — From the in- 
vestigations and hypotheses already mentioned it would be easy to infer, 
in anticipation of clinical observation, that there must be three positions 
in the anatomical sense in which the earliest appearance of cancer of 
the portio and cervix may be made out : (i.) As small nodules deep in 
the tissues of the vaginal portion with the squamous epithelium still 
unbroken. This view follows the hypothesis of Ruge and Yeit as to the 
deep-seated, connective-tissue origin even of papillary growths, although 
such growths apparently arise from the squamous epithelial surface of 
the portio vaginalis, (ii.) As a shallow ulcer on the surface of the vaginal 
portion, a feature due to the origin of the ncAv growth in the most super- 
ficial part of the connective tissue under the pavement epithelium or 
in the " erosion," follicular or otherwise, which in structure is a new 
growth, and is capable, according to the hypothesis, of assuming malignant 
characters. The process thus originating attacks by preference only the 
surface of the vaginal portion, and extends towards the vagina ; never 
upwards through the os externum, (iii.) As a nodule or nodules within 
the OS externum, and underlying the mucous membrane, through which 
the minute malignant growth ultimately penetrates, producing necrosis. 
This form is the clinical result of the malignant process which starts in 
the connective tissue of the walls of the cervix just under the mucosa, 



652 SYSTEM OF GYNECOLOGY 

and it spreads readily along the cervical canal^ but not downwards 
beyond the os externum. 

This is all so plain and obvious that the student might be disposed 
to conclude that the pathology of cancer of the vaginal portion and 
cervix is one of the simplest chapters in gynaecology; whereas, in 
fact, there are few subjects of which the details are more complicated and 
more exasperating ; more elusive of all attempts to grasp and co-ordinate 
them. To complete the theoretical study it would be desirable to ob- 
tain some cases, beyond cavil or reasonable dispute, so early in their 
development as to stamp them as of the squamous-celled portio, of the 
" erosion," or of the cervical mucosa. The cases referred to in Euge 
and Veit's earliest work are not, however, much more conclusive than 
the later observations of Abel and Landau on the corporeal endometrium. 
Chronic endometritic tissue changes were found by them, on microscopic 
examination of the uterus removed by vaginal hysterectomy on account of 
epithelioma of the cervix, to be sarcomatous in character ; a conclusion 
proved to be erroneous by subsequent observers. 

During the last sixteen years I have endeavoured to examine cancer 
cases with some precision and, keeping these theoretic opinions in 
mind as they were published, I have sought for early cases even when 
symptoms did not suggest the presence of malignant disease ; but I have 
never seen a case of flat ulcer, of papillary growth of the portio vaginalis, 
or of carcinoma of the cervix, in which the os externum was not involved. 
Some of the cases have been in the earliest clinical stage, with only a 
very small amount of friable material outside or inside the os uteri ; and 
in all such cases the appearances on examination pointed to the margin 
of the OS externum — the belt of transitional epithelium — as the site of 
origin of the growth. It is quite true that Sir John Williams, in his 
monograph on Cancer of the Uterus, states a widely different opinion on 
the same ground of clinical observation. He says : '' On looking through 
these cases, we find that cancer may begin at any point of the vaginal 
portion from the os uteri to the vaginal vault. It may begin at more 
than one point — at several close together — as in the first case, or it may 
originate at the external orifice as in the second and third cases, or it 
may commence from the surface of a polypus growing from the lip — it 
may begin, in fact, on any point of the cervix covered with stratified 
epithelium." Holding the opinion which he has expressed, that the 
cancerous process always involves the os externum, the present writer 
must submit that Sir John Williams' description of his material does 
not bear out his conclusions. For fear of being mistaken or appearing 
unfair, he has frequently gone over the points of the eight cases described ; 
in only one case was the os uteri uninvaded, and that case, it may 
reasonably be objected, would be better described as one of primary 
epithelioma of the vagina due to the prolonged irritation and " insult " 
of thirteen years of prolapse. Is not the histology as described also 
that of primary cancer of the vagina ? 

From what has been said, it will be inferred that my conclusion 



MALIGNANT DISEASES OF THE UTERUS 653 

is that the distinction usually maintained between cancer of the portio 
and of the cervix is an arbitrary one, and one not supported by the facts 
of cases in actual practice. 

Among others Leopold maintained the same opinion. In a discussion 
on the diagnosis of cancer of the body of the uterus, he supported the 
theory of \yaldeyer, Thiersch, and others, that cancer can only be defined 
as an atypical epithelial neoplasm ; and he endeavoured to prove that to 
separate cancer of the portio from that of the cervix is not in accordance 
with the facts, and is indeed impossible. "Carcinoma of the uterus 
occurs most frequently below the os internum, commencing in the epi- 
thelium of the portio vaginalis ; seldom in that of the mucous membrane 
of the cervix. A large number of cases of so-called carcinoma of the 
cervix are really cases of carcinoma of the portio vaginalis." 

Modes of Ext elision of the Ilcdignant Growth. — Without trenching 
upon the ground that must be gone over in dealing with the course and 
symptoms of the disease, it may be well here to consider shortly the 
modes, including directions, in which the disease spreads in its later initial 
stages, and the forms which it assumes. 

Epithelioma of the portio vaginalis, when it takes the form of flat 
cancroid or ulcer, spreads impartially upwards and downwards. The 
shallow ulceration downwards is most apparent comparatively early, be- 
cause the lip affected long retains its shape, however it may change in 
size and in colour ; but any firm manipulation of the affected cervical 
area, such as the application of a sharp curette, at once reveals the 
extent of the invasion. I have before me microscopic preparations of 
tissue taken from the clear-cut margin of a shallow epitheliomatous 
ulcer where it had just reached the vaginal vault in front. There is 
healthy tissue at one end of the section, and cancerous tissue at the 
other. The surface of the ulcer was clean looking, and the whole 
process seemed superficial, but the cervical canal was excavated into a 
wide crater, and the whole uterus was fixed by infiltration of the para- 
metrium. The same processes are often seen in still earlier stages in the 
same relative advancement; it is purely a question of stage in the 
progress of the disease. The superficial ulcer which destroys the surface 
of the portio vaginalis, the area of soft squamous epithelium, does not 
seem readily to invade the* region of the more cornified epidermis of the 
vagina. The tissues encountered at the line of transition of the epithe- 
lium seem to exercise a certain retarding influence. 

At the external os the process of necrosis, as a rule, destroys the mu- 
cous lining rapidly, and penetrates more or less profoundly the muscular 
tissue of the vaginal portion, although the muscular tissue offers greater 
resistance to invasion than does the mucosa. But beyond the os ex- 
ternum the mucous membrane disappears at a more rapid rate than the 
muscular and fibrous tissue arranged round the os, and consequently, 
even comparatively late, there may be a relative narrowness and firm- 
ness of the parts representing the original os externum. The process of 
ulceration continues, creating a sort of funnel-shaped cavity in place of 



654 SYSTEM OF GYNECOLOGY 

the normal cervical canal, and ultimately reaches the neighbourhood of 
the OS internum. Here, again, there is a comparative arrest of the 
process of necrosis, only more marked than that which is found at the 
junction of the vaginal portion and vagina, or even at the external os. 
In not a few cases the resistance to the ulcerative process is so great 
that considerable hypertrophy both of epithelial and parenchymatous 
elements may result. This hypertrophy in post-climacteric cases some- 
times produces a complete closure of the os internum, bringing about 
the condition of hydrometra which, probably by bacterial invasion, 
ultimately becomes pyometra ; by no means a rare complication of post- 
climacteric cancer of the cervix. 

In the papillary form of epithelioma of the vaginal portion the 
disease begins on the margin of the external os. The earliest de- 
velopment of the tumour which ever came under my notice was that 
of a small growth with the characters of cauliflower excrescence. It 
was growing from the margin of the os externum, and the cervical 
tissue itself did not appear to be invaded. Considering all the circum- 
stances of the case, the operation of total extirpation was recommended 
and performed, and it was found on incision at the external os that 
the cervical tissue was invaded nearly symmetrically all round, and the 
uterus, as a museum specimen at the present time, shows a distinct 
funnel-shaped excavation where the soft papillary growth originally ex- 
isted. It is alleged in several manuals and monographs which I have 
consulted, that the papillary form of epithelioma does not readily in- 
vade the tissues of the cervix uteri, but causes early infiltration of the 
parametric connective tissue. The first time that I witnessed an opera- 
tion upon a uterus affected with cauliflower growth was in the Vienna 
Hospital, over twenty years ago, when Carl Braun operated by means 
of the galvanic cautery. In that case an opening was made into 
Douglas' space; and since then I have more than once had the same 
experience of opening Douglas' space on making the first rapid incisions 
with suitable scissors for the removal of the mass of cauliflower growth 
as the first step in extirpation of the uterus. Such an experience 
implies that more than the vaginal portion of the uterus was invaded 
by the cancerous growth during the formation of the cauliflower mass 
which filled the vagina, and in each case, on completion of the operation, 
it was found that the amputation had been made a little way below the 
internal os. In every case of cauliflower excrescence, even when the 
mass in the vagina was enormously large, the uterus itself was found 
to be movable, and extirpation was considered feasible. So far, then, 
as the spread of the disease is concerned, in a case of papillary 
epithelioma it may be confidently alleged that invasion of the cervix is 
early and constant, and that infiltration of the parametritic connective 
tissue comes comparatively late. 

When invasion of the parametritic tissue does occur in cancer of the 
vaginal portion or cervix, the areas first affected are almost invariably 
in the sacro-uterine folds; not in the broad ligaments, as one sees so 



MALIGNANT DISEASES OF THE UTERUS 655 

often asserted. It is wonderful how distinctly the extent of this inva- 
sion may be made out in the examination of a doubtful case. When 
considerable ulceration has occurred, and especially if there have been 
early infection of the uterus with saprogenetic organisms which pro- 
duce an offensive odour, no decision as to operation or prognosis should 
be given without a careful exploration of the pelvis per rectum. This 
can only be done efficiently after the bowels have been properly pre- 
pared, and the patient has been put under an anaesthetic. It is then 
possible to make out with marvellous distinctness the position and size 
of the various parts of the uterus and its relations ; and if the slightest 
infiltration have occurred in a sacro-uterine fold or anywhere else, it 
can hardly be missed. The condition of one or other fold — and it is 
always one or other in such a case, never both — is often that of a 
curved line of irregular nodules. These swellings are rightly assumed 
to be produced by glandular infiltration and enlargements. Eepeatedly, 
in operating in rather advanced cases, I have gouged out of the para- 
metric tissues small infiltrated glands, like the smallest of those that 
we are familiar with in dissecting the axilla in the operation for mam- 
mary cancer. It is the gradual development of this invasion of the 
sacro-uterine folds, more than any other individual facts in the case, 
which brings about fixation of the uterus. 

The clinical form of the disease at a comparatively early stage, 
sometimes called mushroom growth, arises from hypertrophy of the 
parenchyma of the cervix with softening owing to infiltration of can- 
cerous elements. It is almost always a carcinoma of the cervix uteri, 
and its site of origin is within the os externum. It marks a stage of 
the development of the new growth at which the uterus is almost in- 
variably movable. 

The later stages of the progress of the vaginal portion or cervix may 
be more suitably taken under the symptoms and progress of the disease 
than in treating of the pathological anatomy. 

Etiology. — To know the causes of things is said to be the chief aim 
of philosophy ; and as applied to medicine in no portion of the field has 
greater industry and intellectual effort been expended with less satis- 
factory returns than in endeavouring to get at the causes of malignant 
disease of the uterus. The object sought for has been some clue to the 
intimate nature of cancer with a view to prevention and rational treat- 
ment. This is a pursuit for the general pathologist, not for a specialist 
in diseases of women, but there are well-ascertained facts with regard 
to malignant disease as it affects the female sex which give the study 
of the etiology a special interest to the gynaecologist. 

First, as to frequency of occurrence, malignant disease affects the 
uterus in a very large proportion of all the cases observed ; and to this 
preference is due the fact, well established by statistics, that women 
are much more liable to cancer than men. 

Such statistics are easily available for reference, and need not be 
quoted in detail. The older compilations of figures may be found in 



656 SYSTEM OF GYNAECOLOGY 

Gusserow's classical work on the New Growths of the Uterus, and some 
others will be referred to in the sequel. Statistics proved before Simpson's 
work that in England, between thirty and forty years ago, about twice as 
many women as men died of cancer. Simpson showed that malignant 
disease was about equal in the sexes at or about the age of fifteen ; and 
from this period of life the difference became more marked until between 
the ages of 45 and 55, when the proportion of women to men affected 
was as 3 i- to 1 ; and then it began to approach a more equal distribution. 

When we come to the particulars of sex and organ attacked, we find 
that cancer of the uterus takes the most conspicuous place. Schroeder 
found that of 19,666 women who died of cancer, 6548 were affected with 
carcinoma of the uterus. 

For the Paris hospitals the figures as given by Picot lead to much 
the same conclusion with regard to the proportion of men and women 
affected ; and Picot brings out the fact that in 100 cases of cancer 51 
were malignant disease of the uterus or mamma, and that there were 
more than three times as many cases of the former as of the latter. 

Similar results were brought out by E. Wagner on investigation of 
the post-mortem examinations in Vienna, Prague, and Leipzig. 

In this country, more recently, Sir Spencer Wells again analysed 
the statistics and obtained results, as compared with Simpson's, which 
suggested an increase in the frequency of malignant disease, with a still 
higher ratio of women to men. Leaving aside these general results from 
the examination of vast numbers (32) of cases, we must look to details 
for assistance. Oskar Mliller analysed in great detail 577 cases of can- 
cer of the uterus which were observed at Gusserow's clinic, and brought 
out some very striking facts which suggest more definite conclusions. 

A defect observable in all these analyses, one which greatly lessens 
their value when looked to for practical hints, is the grouping together 
of all forms of malignant disease of the uterus. But, so far as causation 
is concerned, cancer of the portio vaginalis and cervix may be looked 
upon as a disease quite distinct from carcinoma of the body of the ute- 
rus, or sarcoma in either body or cervix. Carcinoma of the body is a 
comparatively rare disease found under conditions strikingly different 
from epithelioma of the portio. It may be put down for the present at 
about 2 to 3 per cent of all cases of carcinoma of the uterus. The pro- 
portion of cases of sarcoma is at present an unknown quantity. The 
cases are practically included in the figures for cancer of the body, and 
therefore they amount to a fraction of the 3 per cent. 

Taking the figures which have been compiled as we find them, and 
applying a logical method of induction by looking for some constant 
point of agreement amidst the bewildering differences presented in the 
analysis of a large number of cases, we are struck with the agreement 
within limits as to the age of the patients. The great majority are 
women past the middle period of their sexual life, if that be reckoned as 
from 15 to 45, and many are beyond it — past the menopause. Gus- 
serow puts together the figures of certain writers, whom he mentions, 



MALIGNANT DISEASES OF THE UTERUS 657 

and reaches a total of 3385 cases of cancer of the uterus. Of these 
women only two were under 20 years of age ; and we may fairly assume 
that these were cases of sarcoma. Of the whole, 1169 cases occurred be- 
tween 40 and 50, and %o^ between 50 and 60. When we make allowance 
for the fact that the number of living women rapidly decreases from 
decade to decade of their age, we see that the number of cases between 
40 and 60 forms a very large fraction of the whole. 

Oskar Mliller found, in the 577 cases which formed the subject 
material of his contribution, more than one-third of the patients were 
under 40 years of age, and in no case was the age under 20. 

In 100 consecutive cases in the out-patient department of the 
Manchester Southern Hospital I find 77 cases sufficiently detailed to 
be safe for reference : of these 1 was under 30, 23 were between 30 
and 40, 28 between 40 and 50, 21 between 50 and 60, and 4 between 
60 and 70. There was no case over 70. 

Of the 54 in-patients admitted to the Cancer Hospital connected 
with Owens College since its opening, 2 were under 30, 11 between 30 
and 40, 28 between 40 and 50, 11 between 50 and 60, 1 between 60 
and 70, and 1 over 70. There was only 1 case of cancer of the bodj^ 
among these, and one case of sarcoma of the uterus. 

We may consider the influence of age as completely demonstrated: 
50 years is the age at or about which the climax is reached. Age 
suggests lowered vitality and tendency to degeneration, but specula- 
tions in this direction have led to nothing. The deteriorated vitality 
of the tissues is common to all women of the same age whether cancer 
is to appear or not. 

Narrowing down from age to race, we find a suggestive fact. It 
may be considered as proved beyond doubt that cancer of the uterus is 
much less common among the negro races, and even among Asiatics, 
than it is among the white races. This fact seems to imply that 
persons more highly organised intellectually and morally are rather 
subject to this scourge than those who are more callous or less intel- 
lectual or imaginative. 

If we now come within still narrower limits, from race to class, we 
meet with a still more striking fact. All observers are agreed that 
cancer of the uterus (without distinguishing the cervix, which would 
make the exceptions still fewer) is most frequently met with in the 
lower ranks of the people of all countries. So marked is the difference 
of incidence, that it might be reasonably affirmed that if we could place 
all the lower orders who suffer from privation and depressing environ- 
ment for a generation or two in the position of the more favoured we 
should stamp out cancer. In his analysis of 577 cases Oskar Mliller 
found that the patients were almost exclusively of the laboiu'ing class. 
My experience is that cancer of the portio and cervix occurs only 
among the working classes ; the apparent exceptions are so few that 
they are hardly worth discussing. This remark applies to private as 
well as to hospital patients. 



658 SYSTEM OF GYNECOLOGY 

Keeping in view age and class, we proceed still further to eliminate 
irrelevant points, and we find that child-bearing has some relationship 
to the causes of cancer of the portio and cervix. Nulliparous women 
are almost immune. Winckel (56) puts his experience on this point 
very concisely : "The large majority of women with uterine cancer are 
married. Of my patients only 1-7 per cent were unmarried, and two- 
thirds of these had given birth to one or more children." 

In the analysis of 100 consecutive malignant cases occurring in 
my hospital practice there is only one unmarried woman (aged 52), 
and she was suffering from sarcoma. Seventy women, of whose cases 
the record is sufficiently full for the present purpose, had borne 412 
children, and had lost of these 219. The total number of abortions 
of the 70 was 68. Thus the average number of children was h-'^, and 
the average loss by death in their families was 3-1. The average of 
abortion was nearly one for each. One woman had borne eight times, 
and when she came under treatment, at the age of 38, she had only one 
child left. Another had borne six, and had aborted twice : she came 
under treatment at the age of 40, and she had then only three left. 
Another had given birth to seventeen living children, and at 43 she 
had seven remaining. One had a record of thirteen children and two 
abortions ; at 40 she had only four living. One had been the mother 
of three, and at 35, when she underwent the operation of total extirpa- 
tion, she had none. Other examples are : at the age of 42, ten children, 
six living, no abortions ; at 45, eleven children, seven living, no abor- 
tions ; at 40, seven children, four living, two abortions ; at 45, ten chil- 
dren, four living, no abortions ; at 48, seven children, one living, five 
abortions ; at 58, nine children, three living, three abortions ; and so on. 
On the other hand, there is one woman of 33, with all her children liv- 
ing, five in number ; one of 52 with her family of eight all living ; and 
another of 47 with her three children still living. There was not a 
barren woman amongst them. These illustrative details as to loss of 
children are given here to obviate repetition ; they will be discussed 
hereafter. 

The highest proportion of nulliparse affected with cancer of the 
uterus which I have seen mentioned is that found by Oskar Mtiller ; 
namely, 5-3 per cent. The number of cases of cancer of the body of 
the uterus is not deducted. 

When we follow such suggestions as possible causal relations be- 
tween cancer of the uterus and constitution, temperament, occupation, 
previous illnesses not connected with infection or traumatism of the 
sexual organs, anomalies of menstruation, sexual excess, and such like, 
we can find no trace of a constant factor. 

What then about heredity, which has taken such hold upon the 
popular imagination ? In reference to cancer of the uterus it appears 
to be a factor of little etiological importance. In Oskar Mliller's analy- 
sis of Gusserow's later cases it hardly appears. Ousserow collected 1203 
cases, including his earlier material, and found only 90, or 7-8 per cent, 



MALIGNANT DISEASES OF THE UTERUS 659 

in which cancer might have been produced, among other causes, by 
hereditary tendency. Picot found a hereditary predisposition in 18 per 
cent of cancer of all organs. But it should be remembered that to trace 
heredity among the class of women usually affected with cancer is a 
difficult process. Genealogy is not a strong feature in the acquirements 
of their class ; it is often very difficult to get with precision the most 
elementary facts in the history of the individual patient herself. 
Heredity, at any rate, has not been shown to be an important factor 
in the production of cancer of the uterus. 

Setting aside irrelevant and questionable evidence as to causation, 
we find some striking points which are fairly constant : (i.) The race, 
one highly developed, although the class attacked does not consist of the 
highest specimens of their race ; (ii.) the social class whose lives are the 
most laborious, monotonous, and careworn of their community; (iii.) 
the domestic relationships of marriage and maternity ; and (iv.), age, a cer- 
tain limited period of the individual life. The age is that of the decay 
or extinction of the functional activity of the sexual organs, and of 
diminishing vitality of the tissues in general. The domestic circum- 
stances and the class of the sufferers imply a vast amount of unhappy 
experience of life. 

On the physical side there is the constant drain on the constitution 
of frequent pregnancy and lactation, sometimes both combined at the 
same time ; for many of these women go on suckling their children 
partly for the sake of economy, partly because they believe lactation 
prevents conception. Parturition means injury to the cervix uteri, and 
not unfrequently still further drains upon their strength by puerperal 
illness. There is to be included almost invariably, also, irritation 
and consequent discharges from the injured cervix and vaginal portion 
of chronically filthy genitals. In addition there is the loss of rest from 
nursing sick children, and the constant clamour of those who are well. 
Many of the women of the class under consideration live laborious lives 
in doing domestic work, or as the breadwinners of ailing, lazy, or dis- 
sipated husbands. We must also keep in mind the chronic deficiency 
of nourishing food and of suitable clothing, and that many live under 
the most insanitary conditions of their own making, which no local 
authority can avert. Too frequently, also, bodily exhaustion and 
mental depression lead to the use of bad alcoholic stimulants, and when 
food is not plentiful the line of excess is easily reached. Alcohol under 
such conditions produces a chronic metritis which is quite characteristic. 

On the mental side there is constant care as to pecuniary means, 
worries from interrupted employment, anxieties from the illnesses of 
husband and children, and grief from frequent fatal termination of 
illness in both young and old. Eighteen per cent of the cases to which 
I have referred as illustrating loss of children were widows. Add to all 
this the constant monotony of the lives of such women ; the lives of 
the men are by comparison interesting and free from care. 

But, it may be asked, What has all this to do with cancer of the 



66o SYSTEM OF GYNAECOLOGY 

cervix uteri ? The relation to physical and mental depression, com- 
bined with local lesions, is not very remote. With some effects of 
emotional conditions upon the uterus we are quite familiar. We know 
that violent emotions produce interruptions of pregnancy, and many 
illustrations of minor injuries directly due to violent emotion might be 
quoted if space permitted. It stands to reason, therefore, that the 
griefs and smaller depressing emotions — from bereavement by death to 
domestic quarrels and insults — by which the women suffer, and on which 
they brood without alleviating distractions, may in time produce serious 
results by a sort of integration of the effects of emotional storms com- 
paratively frequent and therefore little noted. 

Coming to more definite details as to factors modifying nutrition, 
we have also to note the chronic irritation from lacerations of the cervix 
and chronic cervical catarrh. Ubi stimulus, ihijiuxus. Many gynaecolo- 
gists have said that they have never obtained any evidence of a causal 
relation between laceration of the cervix and epithelioma. But have 
they not looked too much to the fissure and the cicatrix ? A cervix that 
has been deeply lacerated undergoes very gradual changes, which show 
that the irritation exists not in the cicatrix, but in the whole of the 
vaginal portion ; and the coincidence of epithelioma and " multiparous 
OS " is too frequent to be explained as mere chance. 

There is also a suspicious frequency of coincidence of malignant 
disease of the cervix and a history of gonorrhoeal infection. Bumm 
has made a statement with which all gynaecologists who have paid special 
attention to the subject of gonorrhoea in women must agree. " The chief 
seat of gonorrhoea in the woman is the urethra and the cervix uteri ; the 
infection of the cervix produces symptoms and distress only at the 
beginning ; when it has once become chronic it may continue for years 
without causing trouble (Beschwerden)." AVinckel {5Q>) may also be 
quoted from among many authors who have given expression to a 
similar opinion : " It seems plausible that such specific diseases 
(gonorrhoeal infection) favour the development of carcinoma." There 
is also an emotional side to this possible factor in the causation of 
cancer. When working at gonorrhoeal infection in women, my experi- 
ence was that a hospital patient suffering from post-nuptial infection 
had, nearly always, to bear also the domestic trouble of a lazy, useless, 
or dissipated husband. When questioned as to the husband's occupa- 
tion the answer came with remarkable frequency that he was out of 
work. The cruelty of conveying infection was not at all likely to be 
an isolated injurious act in the domestic history of such people. 

The conclusion which the facts seem to lead up to is that cancer 
of the vaginal portion and cervix is very largely a morbus miserice. 
What the import of the apparent exceptions may be I do not profess to 
understand, but it seems probable that if the conclusion be in the main 
true, the exceptions when understood will support the law. While 
heredity in the individual is obscure or apparently feebly expressed, 
there may be in the exceptions the expression of the hereditary suffer- 



MALIGNANT DISEASES OF THE UTERUS 66i 

ings of the class ; the comparatively well-cared-f or individual of her 
generation requiring comparatively little of a determining cause to bring 
out that which might have appeared in the former generation, but for 
the absence of the final determining local cause. 

The hypothesis of morbus miserice places cancer of the cervix in the 
same category as leprosy ; and by analogy we may assume that cancer 
may be banished by social ameliorations which will raise the presently 
existing cancer-producing class to the higher level of the presently exist- 
ing immune, just as the disappearance of the horrors in the individual 
lives and environment of past generations has made leprosy in England 
an historic disease. 

The Symptoms and Clinical Course. — In the early stage of cancer of 
the vaginal portion there are no symptoms which could indicate to the 
person affected the presence of a grave disease. There is nothing to 
interfere in the slightest degree with the ordinary course of life ; and 
even if the woman's attention be attracted to certain trifling symptoms, 
her fears are not excited ; thus it is very rarely indeed that the physi- 
cian has the opportunity of observing a case from the earliest onset 
even of the symptoms. The chief symptoms, in the order in which 
they appear before their relations are obscured by the appearance of 
important complications, are haemorrhage, a more or less offensive vagi- 
nal discharge, and pain. The haemorrhage comes from the portion of 
the cervix uteri affected, that is to say, almost always from the free 
vaginal surface at the margin of the portio. It is seldom profuse. It 
appears rather as an irregular slight haemorrhagic discharge from the 
genitals than as the immediate result of traumatism. The injury may 
be x^roduced by straining in constipation, by sexual intercourse, or by 
some other cause implying direct interference with the part affected. 
In the married, haemorrhage post-coitum is perhaps the most constant 
and suggestive ante-climacteric sign. The stimulus to the uterus result- 
ing from the presence of the new growth may be such as to produce a 
noticeable increase in the amount or duration of menstruation, but this 
is not by any means a constant feature at any stage of the disease, and 
its extent has been probably much exaggerated. Before the ulceration 
and infiltration have so far advanced as to make pain a noteworthy 
symptom, a small vessel may occasionally give way, producing a smart 
attack of haemorrhage ; but the occurrence of any considerable or alarm- 
ing haemorrhage, either by sudden profuse discharge or by prolonged 
slight metrostaxis, is not an ordinary feature of the early stage of 
malignant disease of the uterus. 

In women who have passed the change of life haemorrhage is still 
the first symptom of the disease ; but then it usually attracts more atten- 
tion, and leads, upon the whole, to an earlier demand for medical advice : 
yet still the tendency is to waste time. However far advanced in years, 
the patient is apt at first to be satisfied in her own mind that men- 
struation has recurred; and there is a deep-rooted conviction that 
any discharge of the nature of menstruation is beneficial. Post- 



662 SYSTEM OF GYNAECOLOGY 

climacteric pudendal hsemorrhage should always suggest malignant 
disease. 

At or about the menopause the haemorrhage is attributed at first to a 
supposed irregularity, or even flooding, characteristic of the change of life, 
and not implying any pathological departure from the ordinary health. 

Somewhat later in the course of the disease haemorrhage may become 
profuse, and it occasionally continues in a slighter degree for weeks with- 
out intermission ; contributing largely to that condition which we call 
the cancerous cachexia. 

The foul discharge is the second characteristic symptom of early 
malignant disease of the cervix. The discharge is at first entirely or 
comparatively inodorous. This is specially the case in the profuse dis- 
charge from the cauliflower excrescence before the growth has been inter- 
fered with in any way, either in the digital examination of the physician, 
or in the use of a syringe manipulated by the patient herself. The dis- 
charge from the cauliflower excrescence, even in the early stage, is pro- 
fuse ; but it is- comparatively thick and slimy : it is neither serous nor 
mattery. In the earliest stage of all it contains numerous white particles, 
portions of the rapidly growing and necrosing epithelial elements. In 
the case of a superficially ulcerating epithelioma, or in the early stage 
of cancer of the cervix, the discharge is scanty, thin, and serous ; but it 
soon assumes its characteristic turbid, dirty water, and repellent appear- 
ance, and its extremely offensive odour. As a rule it is a profuse dis- 
charge before it becomes a foul discharge. The discoloration of the 
discharge arises, no doubt, from minute extravasations of blood, the ele- 
ments of which become darkened and disintegrated in the serous fluid, 
and under the chemical and bacterial influences at work. The offensive 
odour is produced by the changes which the serous fluid undergoes in 
oozing from the necrosing surfaces, owing to the access of air and ex- 
ternal filth, and to the invasion of saprogenetic organisms. The modes 
of infection by these organisms are numerous and obvious. There is 
always the possibility of an autogenetic infection, as it has been called, 
by bacteria previously existing in the vagina ; and in the disease under 
consideration there is always easy access of infecting material from 
the external genitals, inasmuch as it is a disease of multiparse, in whom 
the vulva and vagina are as a rule flabby, readily gaping on movement in 
a recumbent position, especially on the side. There can be little ques- 
tion also, that all manipulations, even those undertaken with antisep- 
tics in order to cleanse the parts, are capable of producing injuries 
of the affected tissue, slight haemorrhages, and even saprogenetic 
inoculation. 

When a serous offensive discharge has once been set up, it is perma- 
nent ; and however the haemorrhage, or pain, or other symptoms may be 
modified by treatment, the foul discharge, except on total extirpation, 
persists to the end. It may be modified for a time by antiseptics, by 
curetting and other direct treatment, but it is never wholly removed. 

Pain, as a symptom of malignant disease of the portio vaginalis or 



MALIGNANT DISEASES OF THE UTERUS 663 

cervix uteri, comes on comparatively late ; and cases are met with, in 
which the whole course of the disease is run without the pain being 
so severe as to call for the administration of sedative drugs. It may 
be set down as a rule that when the patient at the first interview men- 
tions pain as a prominent symptom, we may expect to find, on physical 
examination, that the disease is well advanced, and that the uterus is 
fixed, or at least in such a condition as to make thorough surgical treat- 
ment impossible or useless. 

It has been so frequently observed that when there is rapid necrosis 
of the vaginal portion producing an open cavity the pain is slight, that 
we might almost generalise to the extent of saying that pain is in inverse 
ratio to the amount of ulceration. 

When the vaginal portion alone is affected there is no pain. The 
onset of pain appears to coincide with the invasion of the parametrium, 
and consequent interference with the mobility of the uterus. The exten- 
sion of the cancerous parametritis ultimately causes pain of a different 
kind by pressure on nerve trunks. This is the origin of the distress- 
ing aching in the groins, thighs, and down the legs, which is usually 
the first painful symptom complained of. 

When the ulceration reaches the vicinity of the os internum, or 
somewhat earlier when the case is one of the hard form of cancer of 
the cervix, we hear of a genuine uterine pain. It is the dull aching 
in the sacral region which now becomes persistent. It may have been 
complained of earlier as comparatively slight at the time when fixation 
of the uterus was beginning. When pain is hypogastric and spasmodic 
at times there is reason to suspect occlusion of the internal os and the 
formation of pyometra. This is probably the explanation of the inter- 
mittent or colic-like character ascribed to the pain in some cases. It 
applies only to post-climacteric cases ; in younger women the extension 
of the disease so as to interfere with the lumen of the internal os, or to 
produce rigidity of tissues in its neighbourhood, must obviously pro- 
duce a characteristic discomfort amounting at the menstrual periods to 
intense suffering. To pressure of infiltration upon uterine nerve, and 
destruction of nerve tissue by ulceration, must reasonably be attributed 
a part of the constant pain referred both to the sacral and the hypo- 
gastric regions. 

Later still in the history of the case an element in the pain is inter- 
ference with the bladder and bowel, or other organ to which the sense 
of pain is referred. And among the local causes of suffering we find 
sometimes, though not so frequently as might be expected, an irrita- 
tion about the vulva from dermatitis or pruritus produced by the 
discharge. 

If the patient live sufficiently long there is added to her sufferings 
a constant dull, depressing pain from the extension of the disease to 
the peritoneum. The peritonitis is rarely acute, and the pain is often 
brought out only by palpation in the course of examination or treatment. 
It is a perimetritis, and it seldom extends beyond the pelvis except as 



664 SYSTEM OF GYNECOLOGY 

a final lesion due to some accident or rupture wMch. makes it general 
and rapidly fatal. 

Perhaps the explanation of the low form of the peritonitis and its 
comparative painlessness is that it is always a late complication. The 
patient is then both anaemic and saprsemic, and from this physical con- 
dition arises largely the characteristic hebetude and apathy. Besides, 
the uterus at this stage has been long fixed by the infiltration which 
also interferes with the ureters, and the resulting uraemia must add its 
contribution to the production of anaesthesia. 

By the time pain has come on and the uterus is fixed we find another 
symptom which, in my experience, is constant; this is nocturnal rise 
of temperature. The temperature may be normal or subnormal in the 
morning, but it rises to 100° or a little higher at night ; and later in the 
course of the disease there may be sudden temporary elevations to a 
much greater degree. The causes appear to be — (i.) the parametritis, 
and in this respect it is much as we find it in a chronic inflammation of 
the circumuterine tissue without abscess formation ; and (ii.) a certain 
amount of sapraemia from absorption at the seat of ulceration. When 
much loose necrosed tissue prevents the free flow of the serous discharge, 
if this friable substance be removed by the sharp curette, and a moder- 
ately strong solution of zinc chloride be applied by means of a tampon 
of lint packed into the cavity, the temperature falls for a few days if 
there be not much cellulitis ; but when the uterus is involved in a pelvic 
mass, the operation produces little or no impression upon the tempera- 
ture. The septic temperature can be removed temporarily with its 
cause ; the parametritic temperature remains constant. 

The absence of symptoms produced by sepsis, even of pyrexia, is 
remarkable, considering the foulness of the ulcerating cavity. It de- 
pends, in all probability, upon the fact that in the invasion of the tissues 
a stratum of non-infective infiltration precedes even the deepest layer 
which saprogenetic bacteria have reached ; and by this advanced stratum 
both blood-vessels and lymphatics are rendered more or less incapable 
of taking up and conveying the soluble poison. Hence also, perhaps, 
the comparative rarity of metastasis from uterine cancer. The freedom 
with which the fluid products of necrosis of uterine tissues can escape 
no doubt also contributes to the same result. 

Among the more general symptoms of cancer of the uterus must be 
mentioned the effects of the disease upon the digestive organs, which 
are almost constant. The most striking fact in this group of symptoms 
is the early occurrence of anorexia in almost every case of the disease ; 
how it arises has not been explained. It is obviously not from any direct 
effect upon the intestines. Later in the progress of the disease it may 
be associated to some extent with the sapraemia which exists during 
ulceration, even if the retention of debris and fluid be slight ; it certainly 
is not caused by the anaemia, which comes later in consequence of the 
serous discharges and haemorrhage. At a more advanced stage we find 
that changes affecting the digestive organs occur as the result of pressure ; 



MALIGNANT DISEASES OF THE UTERUS 665 

this is when the disease has made such progress as to produce a certain 
amount of pelvic peritonitis, or constipation, by the mere mechanical 
pressure of the enlarged uterus or mass of parametritic exudation upon 
the rectum or the lower part of the sigmoid flexure. In this interference 
with the functions of the intestines there are rarely any symptoms 
approaching in severity those which mark the tendency to obstruction, 
as observed in cancer of the bowel itself, or in pressure of the mass of 
tumour on the rectum in pelvic hsematocele. There is a certain amount 
of pressure and a certain amount of paresis ; and these factors alone, 
combined with the loss of flesh, produce a total result which is fairly 
characteristic ; there are abdominal tumidity and softness, and we may 
even watch the peristaltic action almost as clearly as in obstruction of 
the bowel, partial or complete, from intestinal cancer. 

Vomiting may occur comparatively early, long before a mechanical 
cause for it exists. It is not, however, a constant symptom until an 
advanced stage of the disease. In early anorexia it may be produced 
by injudiciously zealous feeding to keep up the strength ; by unsuitable 
food and medicines, or as the result of idiosyncrasj^ Vomiting is an 
important factor in these cases, but not an important symptom. 

Another member of this group of symptoms is irregular diarrhoea. 
As a consequence of the bowel irritation produced by the development of 
the disease, we occasionally find, not extreme constipation or partial ob- 
struction, but painful attacks, with frequent mucous motions, lasting for 
several days, and amounting to diarrhoea. Diarrhoea is a symptom which 
we find at some stage of several diseases primarily affecting the internal 
female sexual organs, and involving loss of tone of the muscular tissue 
of the lower bowel. Such is occasionally the case late in perimetritis, for 
example, and in other conditions besides cancer. AVe frequently find 
this symptom as a result of inflammation in pelvic abscess ; not in the 
early stage of the parametritis, but in the chronic stage, when an abscess 
exists, and is burrowing towards the intestine, and causing a certain 
amount of pressure on it with softening of its tissues. In such a condi- 
tion of the intestine, when it is to a certain extent softened, inflammation 
of the lining is indicated by the occurrence of comparatively small and 
frequent motions, containing a large amount of serum and mucus. In the 
course of cancer of the uterus there is an analogous condition, producing a 
similar form of diarrhoea which, however, is less constant and continuous. 

With regard to the urinary organs the symptoms in the earlier stages 
are not appreciable, whereas in the later stages much distress is almost a 
constant element in the case. In the early stage of cancer we may be 
unable to discover any bladder symptoms at all ; later, when circum- 
uterine structures are breaking down, the ulceration spreads towards 
the bladder more frequently than towards the bowel. Long before the 
septum between the utero-vaginal canal and the bladder is broken down, 
there is cancerous cellulitis affecting the loose tissue between the uterus 
and bladder, and causing irritability of the bladder and frequent micturi- 
tion. Later still, on making a careful examination in such a case, with 



666 SYSTEM OF GYNECOLOGY 

the aid of a bladder sound, we find a suggestion of irregularity and harden- 
ing of the mucous lining of the bladder itself. Invasion is now sufficiently 
far advanced to produce vesical catarrh. Yet this is not the principal 
urinary trouble associated with cancer of the uterus. The principal trouble 
affecting the urinary organs arises from interference with the ureter, not 
with the bladder itself directly, or with the urethra. As the cancerous 
parametritis extends outwards in the broad ligament, the uterus becomes 
fixed. Owing to the position of the ureters they are very liable to be sub- 
jected to pressure. The disease at first may be unilateral, or it may spread 
almost equally on both sides, and consequently the pressure may be on one 
ureter or both. Now the ureter in this cancerous infiltration is not dis- 
placed, as it may become during the growth of a fibro-myomatous tumour. 
The ureter may be greatly displaced by the benign tumour, yet no marked 
symptom of kidney disease be produced. In the course of the cancerous 
infiltration the ureter is embedded, not pushed aside ; the infiltration 
becomes harder, and the calibre of the ureter is encroached upon. This 
constriction of the ureter leads to dilatation of the tube higher up, and 
results in hydronephrosis, pyonephrosis, atrophy, or some other of those 
changes which go on in a kidney the ureter of which is obstructed. 
•The symptoms accompanying these serious changes may be comparatively 
slight ; or there may be signs of marked uraemia. Sometimes when the 
patient may appear to be in danger from the uraemic condition alone, 
sudden relief may be obtained by rupture of the ureter into the ulcerat- 
ing cavity of the uterus and the establishment of a fistula. Such a 
method of relief, however, is not an incident to be counted upon, but it 
may be produced by operation, and has occasionally been done. If symp- 
toms of uraemia once come on, we may, with confidence, conclude that 
the prognosis as to length of life is extremely gloomy ; and it becomes 
worse the harder and more nodular and fixed the mass around the uterus 
has become. This is a point of the very greatest importance in dealing 
with advanced cases of cancer of the uterus, and specially with regard 
to prognosis. When we find, on examining a patient, that there is a 
hard nodular fixed mass, without much ulceration ; when we learn that 
there are irregular hgemorrhages, comparatively small in amount ; and 
we find only a small cavity, or no cavity at all, we may be disposed to 
count on producing considerable amelioration by treatment. There is 
usually in such cases a considerable amount of pain, but we can relieve 
pain ; and inexperience may lead us to take a hopeful view of the case 
seeing that there is no considerable danger from haemorrhage. In such 
cases, if we overlook the signs of kidney complications, we may give a 
favourable prognosis as to length of life, and yet find that the patient 
suddenly dies, or rapidly sinks in a very short time after we have pro- 
nounced the prospect of life to be good. 

When those hard, nodular, non-ulcerating masses are found filling the 
pelvis, one or other kidney may be found distinctly enlarged, giving 
perhaps the impression of being cystic. This is all the more easily 
made out, because of the emaciation characteristic of this advanced stage 



MALIGNANT DISEASES OF THE UTERUS 667 

of the disease. This enlargement should be always looked for in the 
first examination of a case. 

Dilatation of the ureters, till they look like loops of small intestine, 
is by no means a rare condition, as shown by post-mortem examination 
in ursemic cases, and in cases of veiled uraemia. 

Much stress is purposely laid here on this feature of the late stage of 
cancer, as so little guidance is to be found in text-books, and the con- 
dition of the urinary organs is of the first importance in regard to 
prognosis. Late in the course of the disease we may find, as the result 
of the ulceration, fistula between the bladder and the ulcerating utero- 
vaginal cavity ; this is an inevitable result of the cancerous process if 
the patient live long enough. We may find recto-vaginal, or recto- 
uterine fistula, which is a much rarer condition of parts than the vesico- 
vaginal fistula ; or both anterior and posterior fistulas may be established, 
producing the condition of cloaca. By this time the patient is in a very 
miserable state owing to pain and the impossibility of preventing dis- 
charges, foul smells, and irritation. 

Long before this time the " cancerous cachexia " has become estab- 
lished. The haemorrhage, foul and profuse discharge, pelvic pain, irri- 
tability of the bladder, loathing of food, and slight sapraemic and 
inflammatory feverishness, bring about a change in the patient's appear- 
ance which is quite characteristic. It is marked by loss of flesh, a 
peculiar unwholesomeness or yellowish pallor of the whole skin, loss of 
colour of the lips and even of the tongue, occasional puffiness about the 
eyelids, habitual want of animation, or even an expression of depression 
of spirits, and an indescribable air produced by want of rest and constant 
physical suffering. If there be an element of uraemia in the case there 
are superadded the special symptoms which it produces in its slighter 
and slowly developing forms ; chiefly hebetude, drowsiness, and impair- 
ment of vision. 

The final stage of cancer of the uterus does not present any new or 
important S3^mptom. The patient is past the stage of profuse haemor- 
rhage. She is anaemic, uraemic, and sapraemic, emaciated, and, apart from 
quality, the quantity of blood in the body has become comparatively 
small. Owing to this fact, and the weakness that affects the heart as 
well as every other organ, occurrence of severe haemorrhage is rare, 
although exceptionally it may be the immediate cause of death from 
ulceration through the walls of a considerable artery. 

Owing to the increase of the cancerous mass, we may find signs of 
pressure upon the blood-vessels in the pelvis, just as we find pressure 
upon the ureters. There may be some oedema of one or both limbs. 
There may also be pressure on the sacral nerves, producing distressing 
aches or cramps in one or other of the lower- extremities. Later still we 
may occasionally discover thrombosis, which is a comparatively rare con- 
dition, because few of the patients live to the time at which it comes on. 
If we find persistent local areas of oedema, local areas of pain, with 
change of colour about the inside of the thigh, or about the groin, indi- 



668 SYSTEM OF GYNECOLOGY 

eating that thrombosis or phlebitis has oeeurred, then we may feel 
assured that the patient has not long to live. 

Now these conditions, symptoms, and local changes, occurring in the 
various parts, have been described in sequence ; but they develop, of course, 
more or less simultaneously. In this advanced state the patient, as a rule, 
is constantly in pain; in the back, in the groins and thighs, and in 
the hypogastrium. It is a question whether there is any nocturnal 
exacerbation of the pain in the advanced stage when there is a fixed mass 
in the pelvis. If such patients do not receive soothing medicines their 
pain impresses itself more upon them in the sleepless and silent hours 
of the night, but there is no proof from exact clinical observation that 
severe painful exacerbations occur regularly in the night or at other 
definite times like the maximum and minimum of the barometer. 

It is not often that we meet with cases which have run their course 
without medical or surgical interference. Such cases, however, are on 
record, and illustrate the natural history of ulcerating epithelioma 
originating in the vaginal portion. The symptoms may attract so little 
attention throughout that medical advice may not be sought until the end. 

Causes of Death from Cancer of the Uterus. — Supposing we have to do 
with an advanced case, we must consider what facts would lead us to 
anticipate an early fatal termination. In what direction will the compli- 
cations appear which will lead to the inevitable end ? In a large number 
of cases there seems to be no special direction. The patient dies from 
marasmus, from want of nutrition of the tissues, and consequent loss of 
power of the whole organisation — of the muscles, heart, organs of respira- 
tion, and nervous system. We may call it merely loss of strength, or by 
the more pedantic name of asthenia. Occasionally, owing to some com- 
plication, we find peritonitis spreading from the uterus to the pelvis 
generally, and even beyond it ; causing pain and further depression of 
the heart's action. It may also be accompanied by diarrhoea, which 
precedes the fatal termination. Occasionally, in advanced cases, we find 
that the disease spreads to the Fallopian tubes, causing a cancerous form 
of pyosalpinx ; just as we find in some cases that obstruction of the os 
internum with bacterial infection produces the cancerous form of pyo- 
metra. From the tubes the inflammatory process may spread to the 
ovaries and peritoneum. But general peritonitis, from some sudden 
giving way of protective adhesions, or bursting of an abscess of the tube 
or ovary arising from cancer, is of very rare occurrence. 

(Edema of the lungs, heart failure, ascites, are local indications of 
extreme loss of strength. But the commonest of all the complications 
arises from the interference with the functions of the kidneys by 
pressure upon the ureters, though ursemic convulsions are comparatively 
rare. Occasionally, but very seldom, sudden haemorrhage is the imme- 
diate cause of death. Sometimes women who have not been recently 
bleeding to any alarming extent, but who are greatly reduced by all the 
causes that have been already enumerated, suddenly have an attack of 
haemorrhage. In their general condition they cannot stand much further 



MALIGNANT DISEASES OF THE UTERUS 669 



loss, and a sucldea gush of haemorrhage, owing to ulceration through some 
vessel even of comparatively small size, causes syncope, and the patient 
thus suddenly dies. If a tampon were immediately applied the hsemor- 
rhage might be stopped ; but, as a rule, in the sort of case under con- 
sideration skilled assistance is not at hand, and the haemorrhage is the 
final episode in the story. This termination, however, may be consid- 
ered to be comparatively rare. Of the cases that I have had under my 
care, I can remember only two or three in which haemorrhage was the 
immediate cause of death. 

Duration of the Disease. — With this subject of the causes of death 
comes the question as to the duration of life in any given case of 
cancer. This is a question wdiich we are always asked w^hen the 
diagnosis has been finally established ; and it is one that, with the evi- 
dence which is available, we can seldom answer in a manner satisfactory 
to ourselves. Extreme periods have been set down as the duration of 
cancer ; but there are no two cases alike, and any application of averages 
becomes misleading. The patients, as a rule, are not greatly dissimilar 
in certain respects. By the time the first symptoms of cancer show 
themselves, the vast majority of them are in comparatively poor health, 
and if they belong to the same class socially, they have gone through 
similar experiences of life. But the phenomena of the disease may 
widely differ. In some cases, especially in the comparatively young, 
the disease spreads rapidly ; in some cases, especially in the more elderly, 
it has a very slow development indeed. By the time the doctor is con- 
sulted the disease has almost invariably made considerable progress, and 
it is seldom possible to learn with exactitude w^hen the disease began. 
We can, therefore, only guess from the symptoms at the probable dura- 
tion of life in the individual case. We may find a case of infected 
uterus with considerable ulceration in the cavity; and yet we may 
confidently say the patient has a fair prospect of living two or three 
years. The tendency in our predictions is to exaggerate the rate of 
progress Avhich the disease will make, and therefore to make statements 
minimising the patient's prospect of life. But if we take the case of a 
patient who is not suffering pain, and whose uterus is not fixed, we may 
say that the condition is the most favourable to continuance of life. And 
yet w^e are all very liable to make mistakes. By seeing the case only 
two or three times at intervals one can hardly forecast its future progress. 
In a recent post-climacteric case, at the time of the first consultation, the 
doctor in attendance had not made an examination for several weeks 
previously ; at that date he w^as not quite certain of the diagnosis, 
but thought there was a suspicious nodule on the vaginal portion at the 
OS ; slight haemorrhage had also occurred, and had recurred a few days 
before we saw the patient together. On our visit, on the posterior lip 
including the os, there was a distinct, small, ulcerated nodule. The 
patient was sixty years old, and had enjoyed good health. Total extir- 
pation of the uterus without delay was recommended, but the patient's 
objections were not overcome for more than six weeks. No further 



670 SYSTEM OF GYNjECOLOGY 

examination was made until the patient was on the operating table, 
and when the parts were exposed an amazing development was found : 
the small nodule had become a great ulcerating mass ; the whole of the 
vaginal portion was distinctly involved, and owing to vaginitis by con- 
tact posteriorly, it was necessary to begin unusually low down in the 
vagina in order to remove all suspected parts. In such a case as this, 
when an elderly woman with a comparatively small nodule first men- 
tioned the slight haemorrhage, one might have been disposed to regard 
the case as a favourable one, and to estimate the prospect of life at two 
or three years or more. 

When we meet with a patient on whose face the cancerous cachexia 
is impressed, whose symptoms date back for many months, whose uterus 
is fixed and ulcerating, and about whom there is a haunting foetor, how- 
ever slight, we can only look for a short and downward course. We 
may say that the patient will live a year, but we know that a considera- 
ble portion of the time in this last stage will be really passed in intol- 
erable suffering, only to be relieved by the judicious application of a 
process of euthanasia. In such cases, too, we must always look for em- 
barrassment of the kidneys, and keep in mind that there may be a rapid 
or sudden termination in ursemic convulsions, or in hebetude deepening 
into coma which may be their equivalent. 

II. Cancer of the Cervix. — After what has been already said, the con- 
sideration of cancer of the cervix, in the narrower sense, need not detain 
us long, if we direct our attention strictly to carcinoma cervicis uteri, 
and not to those forms of malignant disease which are often described 
as such, but which are certainly, or almost certainly, cancer beginning 
in the circle of the os externum. Such cases should, strictly speaking, 
be regarded as forms of cancer of the portio vaginalis. 

Cancer of the cervix, in the restricted sense indicated, occurs in two 
well-marked forms. In the first of these, if in a comparatively early and 
clearly distinguishable stage, the patient mentions symptoms which sug- 
gest malignant disease. There is the characteristic form of haemorrhage, 
and there is a tolerably profuse and suspicious discharge which may or 
may not have become offensive. Offensiveness of the discharge depends 
upon bacterial infection ; and the cervix is protected from infection in 
the early stage of the disease in the same way as cancer occurring in the 
cavity of the body, but in a less degree. It is the proliferation of 
epithelium, the consequent reaction in the tissues with congestion and 
profuse discharge from the cervical glands, and finally ulceration which 
bring about the characteristic thin, sanious, or dirty water discharge 
from the affected area. Most pathologists, and clinicians who pay special 
regard to pathology, are agreed that the disease originates in the deeper 
cells of the cervical glands ; not more superficially. Sir John Williams, 
for example, on this subject says : "The starting-point of cancer of the 
cervix is, in so far as I have seen, the cervical glands. I have seen no 
clear instance in which the disease originated in the epithelium of the 



MALIGNANT DISEASES OF THE UTERUS 6yi 

surface." This conclusion may be accepted as a representative statement 
of the opinions of the most competent clinical observers. 

As the disease advances, the destruction of tissue proceeds upwards 
towards the os internum, and in this class of case it sometimes invades and 
passes beyond the internal os. At an equal rate, as a rule, it passes down- 
wards, chiefly destroying the mucous lining, and invading more or less 
the parenchyma of the cervix. In the supposed example seen before 
destruction of the vaginal portion is greatly advanced, the cervix will 
be found enlarged, but not usually to a very marked degree. The 
OS externum may be more or less patulous, probably plugged by un- 
healthy looking slime, mixed with turbid or sanious serum ; and the 
first impression on inspection through the speculum is that the case 
is one of marked erosion. There is a ring of eroded mucous lining 
extending more or less widely round the external os. But in the cases 
of which we can speak with confidence, there is something both in the 
colour of this eroded area and in the appearance of the discharge that 
suggests malignancy. The tissues are not found hard, irregular, or 
nodular on the first digital examination. It is the patient's appearance 
which, taken with the symptoms, excites suspicion. If in such a case 
the sound be used, it will give the impression of touching abnormall}^ 
soft and probably irregularly distributed tissues ; and if, on suspicion 
being roused, a suitable sharp curette be passed through the internal 
OS and tried upon the cervical tissue, this will be found soft and flabby, 
and there will be no difiiculty in obtaining shreds, or rather plugs for 
examination. 

In some cases further advanced, where the ring of the os is still 
more or less intact, the curette may break down a portion of the tissues 
surrounding the os uteri, and expose a cavity filled with friable necrosed 
cervical material. At this stage there is still no invasion of parametric 
connective tissue ; and, consequently, the case is in the most favourable 
condition for total extirpation. 

The second form is comparatively rare, but there are points in it of 
great interest from the surgeon's point of view. It may be called the 
scirrhous form of cervical cancer. 

An ordinary case, as met mth in practice when the disease has suffi- 
ciently advanced to make the subject of it seek for medical relief, 
presents on vaginal examination a hard, irregular vaginal portion, sug- 
gesting that peculiar cartilaginous hardness which is often found tow- 
ards the menopause in a woman who has suffered for many years from 
chronic cervical catarrh. Digital examination also usually reveals the 
fact that the uterus is movable, or the movements are only slightly 
embarrassed. The first step in physical examination probably also proves 
that no haemorrhage is produced by touch, and that there is little dis- 
charge. Pain is the symptom which has led the patient to seek advice ; 
hence, probably, the reason why such cases are seen in a comparatively 
early stage of the disease. The patient has usually passed the meno- 
pause, and for years has been free from symptoms referable to the pelvis. 



672 SYSTEM OF GYNECOLOGY 

On examination with the speculum, it is found that the external os 
uteri is comparatively little involved. There is probably a hard, un- 
wholesome, and shallow excavation at some point occupying a portion 
of the circumference of the part. All that is visible of the rest of 
the uterus may appear comparatively ansemic ; there are usually, in fact, 
merely indications of senile changes. Investigation into the condition 
of the cervix with the probe or sound produces only slight haemorrhage. 
If for the purpose of this inspection the vaginal portion be seized with a 
volsella, it Avill be found then that the movement of the uterus downwards 
is much the same as in the later stage of convalescence in perimetritis. 
Movement is only slightly diminished. The sound may be passed 
through the cervical canal, which will be found narrow and irregular. 
In the cases in which I have succeeded in extirpating the uterus the 
body has been found uninvaded and senile. This variety of malignant 
disease of the uterus is the only one which, at the early stage, may 
suggest an exception to the conclusiveness of the evidence produced by 
the sharp curette. It requires firm pressure with the instrument to 
break through the surface of the hard ulcer. 

On further examination of a characteristic case, there may be found 
some indications of invasion of the one or other sacro-uterine fold ; but 
in spite of this, the gynaecologist will probably be strongly tempted to 
X^ronounce the case suitable for extirpation and he may confide to his 
colleague, the general practitioner, that the operation will be compara- 
tively easy. If he proceeds to operation he will find the directly 
opposite to be true. The most striking characteristic of this form of 
malignancy is a comparatively early invasion of the connective tissue, 
both laterally and between the uterus and bladder. There may even be 
adhesions of the intestine in Douglas' space ; and in the course of opera- 
tion extreme difficulty is consequently experienced in reaching the peri- 
toneum either in front or behind. If the surgeon do succeed in extirpating 
the uterus, it need hardly be said that he may anticipate a compara- 
tively early recurrence. 

When the parts removed are examined after extirpation, the cervix 
presents comparatively little hypertrophy, with generally hard tissues, 
and occasionally with harder nodules distributed throughout. In no 
case have I seen any indication of softening. The pain probably arises 
from the early invasion of the circumcervical connective tissue, and the 
hardening of the cervical parenchyma. In one such case which occurred 
several years ago, the operation took over two hours, chiefly owing to the 
firmness of the cellular tissue between the cervix and bladder, and on the 
posterior surface of the uterus between the vagina and the peritoneum 
of Douglas. During the operation the bladder wall was so thinned thait 
a fistula soon afterwards formed and gave rise to great distress. 

I have recently seen another case on which I operated two years and 
seven months ago. Owing to difficulties from the causes indicated, I had 
to rest satisfied with amputation at the internal os, and the use of pressure 
forceps in the left broad ligament, which presented unexpected difficulties. 



MALIGNANT DISEASES OF THE UTERUS 673 

It seems that after convalescence the patient Avent on for two years with- 
out a symptom, and then she was attended by a doctor for several weeks, 
owing to an attack of phlebitis in the left leg after unusual exertion during 
a holiday tour. She complained of nothing further until quite recently, 
when she again called in the doctor on account of some discomfort in the 
groins and some increase in the amount of discharge. This was only a f ew^ 
days before my visit. When we saw the patient together, her chief com- 
plaint was of two large tender masses of glandular swelling in the groins. 
She complained of no abdominal pain, and she said but for the painful 
swellings she would have been " knocking about." On further examina- 
tion there was found a mass filling the pelvis, but capable of compara- 
tively free, elastic movement. There was no ulceration nor appearance 
of unequal consistency in the mass. A prominent feature, however, was 
a large, comparatively soft nodule on the vaginal surface of the urethra, 
with a considerable area of infiltration of the vaginal wall around it. 
This soft nodule is almost certainly a fresh centre of development of 
cancer, wdth a proportion and arrangement of its constituent elements 
entirely different from the original disease; and from this cancerous 
area doubtless comes the glandular invasion. 

Diagnosis. — The diagnosis of cancer of the uterus must be established, 
as in most cases of disease, by the anamnesis, and by physical examina- 
tion. In an ordinary case of cancer of the portio or cervix, in which 
the disease is so far advanced as to rouse the patient's anxiety by the 
persistence of certain symptoms, the diagnosis of cancer is among 
the easiest of case-problems with which the practitioner has to deal. 
There is the history of irregular vaginal haemorrhage, if there be 
nothing else. An irregular vaginal haemorrhage should always lead 
to physical examination without delay. On making a vaginal ex- 
amination in such a case, even when the disease is not sufficiently 
advanced to produce fixation of the uterus, the diagnosis can usually be 
settled by palpation alone. There is either a hypertrophic, hard, irregular 
nodular condition of the vaginal portion of the uterus, which is friable and 
readily bleeds under the exploring finger, or there is more or less of an 
excavation with hard, irregular edges. This condition may affect either 
lip of the cervix uteri ; in cases of old and deep laceration of the cervix 
it invariably at first affects one or other lip. At this stage the disease 
seldom, if ever, invades the cicatrix at the apex of the laceration. In the 
cases in which the disease is further advanced, there is more or less of 
fixation of the uterus with excavation ; seldom, perhaps never, does the 
uterus become fixed whilst the disease is in a stage of mere hypertrophy 
with ulceration of the vaginal portion, or even in fairly advanced cases 
of cauliflower excrescence. Palpation of cauliflower excrescence settles 
the question of malignancy without any further question of physical 
exploration. In the comparatively early stage, should palpation not 
settle the question in the mind of the practitioner, the speculum must be 
brought to his aid. It is only in the cases of flat cancroid or early 
ulceration that any additional information essential for diagnosis can be 

2x 



674 SYSTEM OF GYNECOLOGY 

gained by visual inspection. The ability to distinguish between the 
worst case of cervical catarrh produced by laceration with ectropium, and 
complicated with ulcerating cervical glands, and the earlier stage of pos- 
sibly malignant disease, implies a familiarity with the various phases of 
non-malignant disease of the vaginal portion of the uterus. The malignant 
condition, however early, always presents an appearance of " unwhole- 
someness " which is never seen in the extremest form of non-malignant 
change. Speaking of a case in this early stage. Sir John Williams says 
of the affected portion, " It was not hard, it was not unduly red, it bled 
slightly on digital examination, it did not enlarge, and yet it looked 
vicious." In such a case the tissue would be friable. There is a dis- 
coloration, especially about the edges of the area of invasion, usually a 
darker shade, which can no more be described than can a smell, but which 
is never seen in non-malignant lesions. It is not possible to lay too much 
stress upon the need for diagnosis at this early stage of malignant disease: 
the life of the patient depends upon correctness of early diagnosis. It 
is quite true that temporising is permissible to some extent ; delay may 
be unavoidable in some exceptional cases. In a dubious case it may be 
best to scarify the surface and the edges, in order to open retention 
cysts, and then to apply, for a few days in succession, some medicated 
preparation of glycerine which will not discolour, inflame, or otherwise 
greatly change the appearance of the suspected surface. Pure glycerine 
is a suitable dressing for diagnostic purposes. After much manipulation 
or scarification glycerine with a small proportion of tannic acid, or of 
carbolic acid, or of both combined, is perhaps a better agent for the pur- 
pose. If, after a few days of such an application the trifling super- 
ficial wounds do not present a healthy appearance, the case may be 
looked upon as gravely suspicious. But in this early stage, for diagnostic 
purposes, the great feature of malignant disease, as compared with any 
other possible disease, is the friability of the affected tissue. This fact 
impressed me many years ago, and for a long time I have depended 
largely upon it, as I consider it to be a pathognomonic indication of 
the presence or the absence of malignant disease in the earliest possi- 
ble stage. The method of diagnosis resulting from this great fact of 
friability is one which every general practitioner may apply in order 
to establish a prima fade case. This friability is indicated by the readi- 
ness with which the volsella tears through when there is considerable 
infiltration of the malignant elements ; and, in the less advanced cases, 
by the facility with which one can fill the sharp spoon by a clearly cut 
out portion of tissue. 

If a mortal disease which is local in its earliest stages is permitted 
to become generalised, there must be something very defective in our 
knowledge, convictions, and practice. There is at the present time a 
tolerable consensus of opinion that cancer, affecting the cervix uteri, 
can, in its early stages, be successfully dealt with as a local disease. 
All specialists in gynsecology, who have turned their attention to 
the operative treatment of cancer of the uterus, lament the smallness 



MALIGNANT DISEASES OF THE UTERUS 675 

of the number of cases that come into their hands at a suflB.ciently 
early stage to give them a reasonable hope that the operation of extir- 
pation will be followed by a full measure of success. Of such com- 
mon occurrence is cancer of the uterus that cases are continually 
coming into the hands of all general practitioners ; and it is on their 
promptness in recognising the nature of the disease, and in dealing with 
it in the most efficient manner at present known to us, that our hopes 
of any considerable improvement in practice must rest. Most of the 
difficulties in the Avay of obtaining more satisfactory results in the 
surgical treatment of uterine cancer arise from the circumstances under 
which the disease occurs, and its early symptoms. 

For the prompt and efficient treatment of the cases which come under 
our observation in the early and favourable stage, we must largely depend 
upon a definite and easily applicable method of diagnosis. Cancer of 
the cervix uteri in the ulcerative stage has such marked characters, and 
is consequently diagnosed so easily, that delay in applying to it the 
radical surgical treatment, if it has not already passed beyond the point 
at which such treatment can be of service, is, with our present available 
knowledge, altogether unjustifiable. There is, however, a still earlier 
stage of the disease which occasionally comes under the observation 
of the practitioner, the most hopeful stage from the point of view of 
surgical interference, which is too often allowed to pass because of doubt 
as to the significance of the facts observed and consequent feebleness in 
action. Any method of diagnosis depending upon features which are to 
be looked for in any given case, and when observed, accepted as sufficient 
to justify action, must be generally available, and easy of application by 
the general practitioner. In order to attain the maximum amount of use- 
fulness, such diagnostic signs must be found with comparative ease when 
looked for, and their verification must not -require any processes which 
demand a large amount of time and care and special knowledge. The 
chief objection, as a method of diagnosis, to microscopic examination of 
tissue obtained from a portion of the organ suspected is the difficulty of 
its application. It requires special knowledge of the methods of obtaining 
and preparing tissues for microscopic investigation ; and even when the 
practitioner possesses the needful knowledge, the amount of time required 
for the application of the method greatly diminishes its value. In addition 
to that, we have to remember that the mere histological examination of 
tissues can only be looked upon as an auxiliary and complement to the 
observation of clinical facts, not as a substitute for it. It may be said with 
confidence, therefore, that the usual advice given in books and clinical 
lectures, under the head of diagnosis of cancer of the cervix uteri, to make 
a histological examination of the suspected tissues, is assigning too impor- 
tant apositionto a proceedingof more apparent than real usefulness. What 
we require is an easily applied clinical method of diagnosis, such as will 
distinguish early cancer from any other condition which a practitioner of 
average knowledge and intelligence could possibly mistake for it, — a 
method which gives at the same time a moral certainty, or at least the 



676 SYSTEM OF GYNAECOLOGY 

very strongest presumption that the diagnosis depending upon it is cor- 
rect. Such a method of distinguishing between early cancer and other 
conditions which more or less resemble it, is that of applying the test 
of friability of tissue which is characteristic of malignant disease. 

If in any given case under examination the results obtained by 
palpation and the closest visual inspection still leave some doubt in 
the mind of the practitioner whether the condition be early cancer of 
the cervix, the doubt will, in my opinion, be invariably cleared up by 
ascertaining the amount of friability of the tissues. The suspected 
vaginal portion must be thoroughly exposed by a suitable speculum, and 
the uterus held steady by the volsella. Then with the sharp curette or 
spoon an attempt is made to scoop out some tissue from the suspected 
area. If the disease be malignant a definite compact piece of tissue, 
larger or smaller according to the extent of the infiltration and conse- 
quent friableness of the tissue thus operated upon, will be obtained. If 
the disease be not malignant, a firm rub with the sharp curette will 
only make the part bleed, and, at the most, some small thin threads or a 
pellicle of semi-translucent epithelium or of granulations will be detached. 
The difference is very strikingly brought out by comparing the effects 
thus produced upon a case of old chronic cervical catarrh, marked by 
hypertrophy, ectropium, and retention cysts, with the effects produced by 
similar forcible application of the spoon to the tissues in the early stage 
of epithelioma. The existence of this contrast, with its easy application 
to diagnosis, is of the greatest importance in general practice ; inasmuch 
as chronic cervical catarrh, complicated with the other tissue changes just 
mentioned, is very common, and is almost the only condition at all 
likely to be mistaken for early epithelioma of the cervix. If we 
take, for example, two ordinary cases, one of malignant disease, the other 
of erosion with retention cysts, the characteristic difference does not 
appear on simple inspection. In the case of malignant disease the ring of 
the external os may be complete, and the differential diagnosis by simple 
inspection would have to depend upon a mere shade, an indescribable 
difference in the colour of the mucous lining, and on some differences in the 
colour and degree of thinness of the discharge at the os in the respective 
cases. A comparison between the results to be obtained by palpation 
does not bring us much further towards the completion of a differential 
diagnosis. In both cases there may be a certain amount of hardness, 
unevenness, and irregularity in the consistency of the tissues about the 
external os ; in both there appears to be some hypertrophy of the cervix; 
but there is nothing, so far as touch is concerned, that would justify us in 
saying that the one case is malignant and the other is not, and in acting 
accordingly. Now from certain facts in the clinical history of the 
malignant case, not in themselves conclusive, the nature of the disease 
is suspected, and the test of the sharp curette is applied. The instru- 
ment cuts through, from inside the os downward to the vaginal surface 
of the portio, as if through a radish; and although a microscopic 
examination of the tissues may still be made, the diagnosis may be 



MALIGNANT DISEASES OF THE UTERUS 677 

considered complete on observing the effects of the curette, taken in 
conjunction with the other clinical facts, quite independently of the 
histology. I have found, on extirpation of the nterus in such a case, 
a condition of considerable ulceration with extensive softening and 
breaking down of the tissues within the cervix uteri, extending even 
above the internal os. 

Quite recently I had the opportunity of dealing with a case which 
formed a striking illustration of the application of this method of 
diagnosis ; the clinical history, including haemorrhage, the appearances, 
and the impression obtained by palpation supported the diagnosis, 
already confidently arrived at by a colleague, that the patient was 
suffering from epithelioma of the cervix uteri. On the posterior lip of 
the deeply lacerated cervix was a considerable area apparently devoid of 
epithelium, and with an irregular indurated margin studded with small 
retention cysts, some of which were ulcerating. The test of the sharp 
curette was applied with a negative result, — that is to say, the suspected 
surface was merely made to bleed, and some thin particles of epithelium 
only were scraped away. A distinct mass of friable uterine tissue was 
not obtained ; nevertheless the appearance of the hypertrophied eroded 
posterior lip was so suspicious that it seemed as if an exception to the 
rule had been found, and that the test, as a universal test, had failed. 
The patient was kept in bed for several days, and medicated tampons 
were applied in order to cleanse thoroughly, and as far as possible 
modify the appearance of the suspected area in a healthy direction. 
The change which took place was of small avail for completing the 
diagnosis, and the sharp curette test was again applied with the same 
result. It was, therefore, decided to proceed with Emmet's operation, 
as the most effective method of dealing with the laceration and hyper- 
trophy ; inasmuch as the definite conclusion was reached that the 
erosion and other changes could not be OAving to malignant disease. 
In performing the operation the incision on one side invaded the 
margin of the ulcer, and this was followed immediately by a gush of 
the fluid characteristic of a retention cyst of the cervix, and the hard 
and apparently hypertrophied posterior lip at once became flaccid and 
greatly diminished in bulk. This retention cyst of the cervix was the 
largest that I have ever seen. The operation was completed, the patient 
made a perfect recovery, and I heard some weeks afterwards from her 
medical attendant that the symptoms which originally caused alarm 
had subsided, that the uterus appeared perfectly healthy, and that it 
was almost impossible to make out the points of union in the ring of 
the perfectly restored external os. 

It would be out of place to illustrate the method or to elaborate 
the description further. I have applied it myself for about ten years, 
and have never found it to fail. The suitable application of it pre- 
supposes a reasonable amount of knowledge of the diseases of the female 
sexual organs, and the due consideration and appreciation of all the 
relevant clinical facts in any given case ; when any doubt still remains 



678 SYSTEM OF GYNECOLOGY 

in the mind of the practitioner, the effects produced by the sharp curette 
or spoon should finally settle the diagnosis as to malignancy. 

When the operation of vaginal hysterectomy for cancer was being 
introduced into this country, one of the objections raised by some of 
the senior gynaecologists to such a serious operation was the extreme 
difficulty of diagnosing cancer of the cervix sufficiently early. But 
there never was any such extreme difficulty in diagnosis as used to be 
alleged; and more exact observation of the injuries done to the cervix 
in parturition, and of the subsequent and resulting changes in the in- 
jured parts which may take years to establish, has done much to mini- 
mise or remove any reasonable ground for doubt if it ever existed. It 
is only in such cases of injury that doubt as to the benign or malignant 
nature of the changes is excusable. All the other appearances usually 
enumerated as simulating cancer have only a superficial resemblance to 
it ; ignorance and carelessness are essential to mistaken diagnosis. 

The use of the curette in the differential diagnosis of malignant 
disease of the body of the uterus is better known, but it is perhaps not 
adopted so generally as it ought to be. Friability is characteristic of 
the malignant growth here as well ; but other friable structures may be 
found fixed in the body which are only found detached in the course of 
expulsion in, the cervical canal. 

English gynsecologists who have given special attention to cancer do 
not, as a rule, err in depreciating the value in exact diagnosis of clinical 
work as compared with microscopic examination; but there may some- 
times be room for improvement in clearness of statement of the value of 
each method of diagnosis and of their mutual relationships. 

Specialists in diseases of women and pathologists usually assure the 
general practitioner that the diagnosis of cancer in its earlier stages is 
not complete without microscopic examination. Such an assertion dis- 
courages exact clinical observation, and is equivalent to telling the gen- 
eral practitioner, with comparatively few exceptions, that he is incapable 
on account of ignorance, or disabled by the exigencies of his professional 
life, from forming a sufficient diagnosis in a class of cases of frequent 
occurrence, and in which such serious practical consequences may follow 
his mistakes. It is, moreover, misleading in that it attaches undue 
weight to a method of diagnosis which experience proves to be unde- 
serving of such implicit confidence. 

Sir John Williams, in his work on Cancer of the Uterus, says quite 
truly that clinical observation is, as a rule, not equal to making the 
distinction between the different kinds of malignant diseases. But he 
understates the case for clinical observation, when he says that '^ weeks 
or months of watching " may be necessary to decide whether a growth 
be malignant or not; and he overstates it on the other side when he 
says : '^ During the early stages of cancer or of other malignant growths, 
the microscope, I believe, will enable us to recognise and make sure of 
the disease long before clinical observation." 

Mr. Knowsley Thornton, speaking in favour of clinical observation, 



MALIGNANT DISEASES OF THE UTERUS 679 

called attention to an objection to microscopic examination which, is too 
often overlooked. He said: '' To snip out a bit of a malignant growth 
is in truth to perform a partial operation, and thus to run the risk of 
rapid spread to distant parts through the opened veins and lymphatics. 
Clinical observation, if sufficiently close and painstaking, will generally 
give a distinct diagnosis in good time for successful interference." 

On the other hand, Dr. W. S. A. Griffith goes the length of assert- 
ing: "In all doubtful cases of disease of the cervix a piece of the 
suspected part should be cut out, taking care to include the margin of 
the healthy and affected part, and be carefully preserved and submitted 
to microscopical examination." Thus implying, we may assume, that 
the question will be settled ; they will be no longer " doubtful cases." 

Dr. Herman, speaking on the same subject, says: "I think the 
value of the microscope in the clinical diagnosis of cancer has been over- 
estimated. ... A diagnosis based on the microscopical examination 
of sections of tissues must be accepted with great reserve." 

It may be stated broadly that every German, and almost every 
Continental gynsecologist, supports the opinion of the importance of 
microscopic examination in diagnosis. Winckel says that " it is evident 
from the pathology of carcinoma that in its earlier stages the disease 
can be recognised onl}^ by the aid of the microscope. This will reveal 
the characteristic atypical epithelial proliferation in the tissues, and the 
consequent destruction of the latter." 

Auvard, who is almost an exception, devotes much space to the clinical 
features in establishing the diagnosis ; and he quotes Cornil to show that 
even with the microscope differential diagnosis may be impossible. " An 
excised portion of the tumour most frequently permits an experienced 
eye to arrive at an anatomo-pathological diagnosis ; that nevertheless there 
are cases of malignant adenoma (epitheliom) in which it is difficult to 
make out any distinction from the structure of simple adenoma." 

Gusserow (14), in speaking of the early stage of epithelioma and the 
difficulty of differentiating from erosion, admits that erosion has been 
considered by some observers as the initial stage of epithelioma, while 
Huge and J. Veit maintained at first that they were the beginnings of 
true carcinoma. Gusserow, believing that results beyond suspicion could 
not be obtained from small particles of the diseased tissue, in suspicious 
cases practised amputation of the entire vaginal portion in order to 
obtain suitable sections for microscopic diagnosis, even at the risk of 
now and again operating unnecessarily. 

Carl Ruge (41) says : " At the present time it must be the task of 
the physician to recognise cancer as such in its early stage, and this is 
possible in ver^^ many cases only by means of the microscope." 

Such opinions are held by men who know that hyperplasia of the 
uterine mucosa has been mistaken for sarcoma, and that many original 
papers have been written quite independently in support of the discovery ; 
that the decidua of a, jjost-abortum uterus has been diagnosed as sarcoma ; 
that degeneration of the placenta has been found to be like a gumma of 



68o SYSTEM OF GYNECOLOGY 

the liver ; — mistakes all made by pathologists who were specialists in 
gynascology. If this is to be the ultimate position of microscopic 
diagnosis in gynaecology, then the diagnosis of early cancer, on which 
so much of success in treatment depends, must in this country remain 
entirely in the hands of some junior members of the teaching staffs 
of metropolitan hospitals and provincial medical schools during the 
otiose portion of their professional lives. And how many of them have 
had the necessary experience in observing the peculiar character stamped 
upon malignant disease as it occurs in the uterus ? Every man who, at 
some period of his comparatively youthful career, acquired some dis- 
tinction in the study of Greek, must remember the ineffable contempt 
with which in those days he listened to elderly men speaking of the 
extent to which they had forgotten their classics ; and the same man at 
five-and-forty must in his turn look back with humility or amusement 
upon their early notions when they find themselves unable to read with 
ease a verse of the Greek Testament. As with youth and the " ton- 
sured head in middle age forlorn," so it is with the aforesaid junior 
teaching members, and even the best educated and most experienced 
and thoughtful of elderly general practitioners. I have no hesitation 
in saying that diagnosis by microscopic examination, as far as the 
general practitioner is concerned into whose hands come the over- 
whelming majority of cases of early cancer of the uterus, is simply 
impossible. If you take, for example, the description by Euge and 
Veit of the appearances of non-malignant papillary or glandular erosion 
of the cervix uteri, and their opinions with regard to the appear- 
ances of non-malignant compared with malignant changes within the 
same area, their statements add to our difficulties. They say that there 
is no clear border line, so far as histology is concerned, between the 
benign and malignant changes ; and it requires a long and concentrated 
experience, and the special knowledge and acquirements of a professional 
pathologist who has given much attention to gynaecology, to make out the 
difference with such clearness and confidence as to guide him to a con- 
clusion on a question implying such serious practical consequences as 
whether a tissue change in the uterus be benign or malignant. Though 
strongly impressed, through the experience of many years, with the 
importance of clinical observation as compared with the microscopic 
examination of tissues in the diagnosis of cancer of the uterus, as well as 
in many other diseases of women, I have been afraid of the responsibility 
of formally expressing opinions in a public and permanent form, which 
might, however unconsciously, be the mere indication of a prejudice, 
rather than of a definite induction stated with a practical object. I will 
confess, also, to a shrinking from the accusation of want of scientific 
knowledge. All of us do not yet see the greater and the less in some 
of these matters in their just proportions ; and it is as fatal at the 
present day to the professional character of a man to be accused of 
being merely a clinician (a thing which it is assumed that any man may 
be) as compared with being a scientific histologist, for which compara- 



MALIGNANT DISEASES OF THE UTERUS 68 1 

lively few men have the op]3ortunities or the peculiar gift, as it is 
for the moral character of a man to take up a strong position on cer- 
tain social questions. The motive of one is assumed to be ignorance of 
pathology ; of the other to be sympathy with immorality. Ruminating 
on this curious fact, and impressed with the importance of calling atten- 
tion strongly to the need for exact clinical observation of uterine cancer, 
I came to the conclusion that any expression of opinion from me, even 
adequate to the strength of my convictions, would be of no avail under 
present misconceptions as to relative values in professional investigation 
and practice ; and I thought it prudent to appeal to my friend and 
colleague, Professor Delepine, to describe concisely the shortest possible 
methods by which the general practitioner could obtain histological 
evidence sufficient to justify him in coming to a definite decision as to 
the malignancy or non-malignancy of a disease of the cervix uteri by 
means of the examination of a portion of tissue excised or curetted from 
the suspected area. His account of a rapid method of examination 
may be of use to others besides the brethren who are engaged in general 
practice. 

Description of the simplest methods ivhich luill give triisticorthy results in the 
microscopical examination of tissues of the cervix uteri for diagnostic 
purposes {Professor S. Delepine). 

" There are two rapid methods which can be used with success. The 
first consists in freezing the tissues immediately after removal, or within 
a few hours. The other, a little slower, takes about twenty-four or 
forty-eight hours, but is much easier to carry through. 

" The freezing method consists in taking a small piece of tissue, the 
most resisting and fibrous looking parts being selected Avhen choice is 
possible. This piece is dipped into some mucilage of gum arable, and 
placed at once on the plate of a freezing microtome. It is partly frozen 
through. The upper incompletely frozen parts are removed, and then 
a few sections are cut from those parts which have not yet become too 
hard. These sections are transferred, one by one, by means of a soft 
brush, into a dish containing Miiller's fluid, or a 2 per cent solution 
of bichromate of potash. The sections are left in this solution for a 
few minutes, or even for an hour or two ; and then they are spread care- 
fully on a slide. They may be stained on the slide with lithium picro- 
carmin, and mounted in Tarrant's solution ; or they may be stained with 
hsematoxylin, or haematein, and double stained with eosin (weak solutions 
in spirit diluted with 4 parts of water), or rubin and orange. They 
can then be mounted in Canada balsam after the usual treatment ; 
namely, dehydration by absolute alcohol and clearing in oil of cloves, both 
carried out as rapidly as possible. In either case it is Avell to wash off 
the Miiller's fluid rapidly before using the stains. This method, which 
has been employed in my laboratories for over ten years, gives good re- 
sults when the tissues are suitable ; but it requires a certain amount of 



682 SYSTEM OF GYNECOLOGY 

practice, as the sections when cut fresh have a great tendency to curl 
or stick together, and also to shrink during the process of mounting, 

" The other method, which requires a little longer time, consists in 
placing small pieces of the tissues to be examined in ordinary methy- 
lated spirit. The pieces should not be larger than a small bean, and the 
quantity of spirit should be at least twenty or thirty times the bulk of 
the tissues to be hardened. At the end of twelve to twenty-four hours it 
is already possible to obtain tolerably good sections from such pieces ; but 
it is better, when time allows, to transfer them at the end of that time 
to absolute alcohol, and to leave them in it for a few hours. On taking 
the specimens out of the alcohol they are placed in running water for 
one or two hours ; thence they are transferred to mucilage of gum 
arabic in which they are left for about an hour, or for three or four 
hours if they are rather soft. Then sections are cut by means of a 
freezing microtome, the sections being received in water and stained 
afterwards on a slide, either with picrocarmin or rubin and orange. 

" These methods do not give results which can be compared with those 
obtained by more complete methods of fixing and hardening by per- 
chloride of mercury or chromic acid, and passage through alcohol of 
increasing strength, but they are quite sufficient for diagnostic purposes. 
I have lately tried quick hardening by means of the formaldehyde 
method, and found this method satisfactory ; but it does not present any 
considerable advantages over the slightly longer alcoholic method." 

We need have no hesitation in saying that busy men, almost without 
exception, will declare that if such proceedings are essential to the early 
diagnosis of cancer, then most of the cases that come into their hands 
must remain undiagnosed until more obvious malignant characters have 
been developed. The history of the case, often so difficult to obtain with 
preciseness and cleared of irrelevances, and the knowledge acquired by 
exact physical examination, that is to say, the clinical facts, keeping 
always in mind the great feature of friability of tissue, are sufficient 
to establish a prima facie conclusion as to the nature of the case to 
be dealt with. When the clinical test establishes at least a very strong 
presumption of malignancy any further evidence to be obtained from 
the histology of the scooped out portion of tissue may be sought for 
according to the special circumstances of the case. But after the 
application of the clinical test the chief help will be found in closely 
watching the changes which take place in the wound, and these are 
sufficient evidence in every case in which malignant disease of the cervix 
might possibly occur. 

When the other points on which a diagnosis in the early stages may 
depend are under discussion we still occasionally hear of Spiegelberg's 
criteria. These were (1) a closer adhesion of the mucous covering of the 
portio to the parenchyma in the case of malignant disease; and (2) the 
difficulty of dilating the cervix affected with any cancerous process by 
means of tents, and the continuance of the hardness after dilatation, 



MALIGNANT DISEASES OF THE UTERUS ■ 683 

simple induration disappearing under tlie softening influence of the tents. 
This opinion has not received much support, although it has been much 
quoted and discussed. It will probably be considered quite sufficient 
guidance to their contemporaries to say that Winckel and Gusserow 
consider the criteria altogether illusory. 

When we come to consider the local conditions and appearances 
which may give rise to suspicion of malignant disease of the vaginal 
portion or cervix, while the general state of health, which may be 
deteriorated, does not exclude the possibility of malignancy, the most 
common case for doubt is that of chronic cervical catarrh, with laceration, 
ectropium, and extensive " erosion." Still further, if in such a case there 
be also present chronic retroflexion, resulting from injury in parturition 
followed by subinvolution, there will be considerable added hypertrophy 
and other changes of the posterior lip. When the results produced by 
all those factors are present in the same case the nearest approach to 
malignant disease which we know of is reached. This is the sort of 
case in which doubts which are not to be cleared up by rest, temj^orary 
medication, scarification, and similar measures, are set at rest by the use 
of the sharp curette. 

The next class of case in order of the frequency with which doubts 
arise and mistakes are made, is that of necrosis of fibroid polypus with 
partial expulsion from the external os. Such cases are frequently sent to 
the specialist for diagnosis, and I have seen a considerable number of them. 
The most recent was that of a woman in the last stage of ansemia and 
saprsemia owing to the partial expulsion of an enormous mass of fibro- 
myoma. The process had been going on for many weeks, and the mass 
had become partially necrosed ; it thus permitted the flow through it of 
a large quantity of serum, which showed externally as a turbid, filthy 
discharge ; malodorous likewise, but not approaching in i ntensity the 
smell of the discharge from a cancer in the advanced stage which was 
thus simulated. Owing to the retraction of the ring of the os the first 
impression taken from superficial examination of the case was, that a 
large gangrenous cancer mass represented the uterus, Avhich was itself 
fixed by infiltration in the pelvis. The character of the discharge and 
something in the history led to a careful examination under very un- 
favourable circumstances, and the ring of the external os was discovered. 
This is the diagnostic feature ; the ring of the uterine tissue is found to 
be intact, homogeneous, and smooth. Cases of this class seldom present 
more than a momentary difficulty. In all the cases which I have seen 
it has always been the repulsive appearance of the sloughing mass that 
has led to the erroneous diagnosis. An inexact clinical history in which 
symptoms are accepted as occurring in the order in which the patient 
describes or mentions them, a perfunctory examination of the parts 
that can be brought into view, and want of attention to differences in the 
appearance and smell of the discharge, which certainly does not invite 
close investigation, are sufficient to keep up the supply of cases in which 
such mistakes in diagnosis are made. 



6S4 SYSTEM OF GYNECOLOGY 

In the more advanced stages of cancer of the cervix the fact that a 
malignant disease exists is as obvious as in advanced cancer of the breast; 
or in diffuse ulcerating and offensive epithelioma of the vulva. Occasion- 
ally, though rarely, we see malignant ulceration of the cervix with com- 
paratively little discharge and comparatively little discoloration. The 
margin of the ulceration is as definite to touch and sight as that of a 
soft venereal ulcer of the labium. In such cases the question always 
arises, Is the disease malignant or specific ? Much library writing has 
been devoted to the differentiation in such cases between cancer and 
syphilis. My experience of English practice leads me to the conclusion 
that syphilitic ulceration of the vaginal portion of the uterus is among 
the rarest of the diseases of women. I have several times in the earlier 
years of special work suspected syphilis, and temporised accordingly, 
in order to see the effects of general and local antisyphilitic treatment ; 
but in not one single case has the ulceration turned out to be other than 
malignant. There can be no doubt, however, that a real difficulty might 
arise owing to the extent of ulceration sometimes produced by syphilis 
in elderly subjects with constitution ruined by other causes as well. 
The difficulty may be increased by the fact that a history of syphilis is 
to be found in cases of well-marked and unmistakable epithelioma, with 
a frequency not to be accounted for by mere coincidence. Winckel says 
the difficulty is so great in some cases that experienced specialists in 
venereal diseases have sent patients to him for his opinion. Obviously 
under such circumstances there is no simple infallible and universally 
applicable rule. The syphilitic lesions, early and late, do not necessarily 
involve the os externum — malignant disease always does. The syphilitic 
ulcer extends towards the os, the malignant ulcer from it — either over 
the free surface of the vaginal portion, or upwards in the cervical canal. 
The syx-)hilitic lesion has little tendency to bleed, and is not friable ; the 
malignant lesion differs from it in both these respects. 

A detailed history of the case, including the dates of syphilitic mani- 
festations, the appearance of the ulcer when clean, permitting close 
inspection of the points that make for malignancy or otherwise, and the 
immediate effects of treatment, should make diagnosis possible even in 
the most obscure case without much loss of time. 

Some Continental writers make much of the difference between 
papillary malignant disease of the cervix and pointed condyloma. No 
advantage can result from the accumulation of distinctions and differ- 
ences of such small account from the practical standpoint. I doubt if any 
man ever saw a case of condyloma affecting the cervix uteri, for example, 
in a pregnant woman, in Avhich condylomas were not also obvious in 
the vagina, on the vulva, perineum, or even in the groins ; and if any 
practitioner, desiring to be pedantically and logically correct in his 
diagnosis, imagines there could be any question in a case of condyloma 
as to the nature of the disease, the careful separation of the elements of 
a papillary condylomatous mass or tuft, and the inspection of the rela- 
tions of these elements to one another, to the common portion at the 



MALIGNANT DISEASES OF THE UTERUS 685 

base, and the relation of that base to the intact underlying cutaneous or 
mucous surface, must set his mind at rest. He will note, moreover, the 
results of keeping the parts clean with an astringent antiseptic, the 
effect of cutting away some of the tufts, of the application of nitric 
acid to a selected spot, and of microscopic examination. 

Cases have occurred in which partial retention of products of concep- 
tion have led to some difficulty in settling the question of malignancy. 
A shred of placenta, or a plug of decidual tissue sticking in the os 
externum, has been supposed to be cancer, and conversely. When prod- 
ucts of conception are retained, and partly visible through the ring of 
the OS externum, there is something in the colour and consistency of 
the healthy os all round the ring which is unmistakable. There may 
be ugly debris, some haemorrhage, or sanious and evil-smelling discharge ; 
but the suspected substance is free to be lifted away with forceps, and 
the uterine substance is not irregular to the touch : it is homogeneous, 
and it is healthy in colour. But the chief aid to differential diagnosis 
in such a case is a clear detailed clinical history ; when such a history 
is obtained the diagnosis is complete. 

Prognosis. — The prognosis in cases of cancer of the vaginal portion 
or cervix uteri cannot now be laid down on the old considerations of the 
causes of death in such cases, and the probable duration of life while 
these causes are doing their work without interference. 

Prognosis now depends upon what can be done ; and what is prac- 
ticable and beneficial, and what is impracticable and harmful, depends 
upon the stage of development which the disease has reached, and to 
some extent upon the special area affected. 

We first think of operation. If vaginal hysterectomy is feasible, we 
estimate the risk to life from the operation, and the possible permanent 
or temporary immunity from recurrence. These are questions which can 
be best dealt with under the head of Eesults of Operation. We have 
only, therefore, to consider the inoperable cases. We know that here a 
fatal termination is inevitable, and we must consider whether there are 
any measures which may appreciably retard the i^rogress of the disease 
and diminish the sufferings of the patient. By this time the uterus is 
fixed, or there is such obvious lymphatic infection that extirpation w^ould 
be useless, even if practicable. We must then consider mainly the fol- 
lowing points all brought out under symptoms and clinical course: 
(i.) Is the disease of long standing according to the data obtainable ? If 
the symptoms can be traced back to a longer than average time, then the 
progress of the disease is slow ; if it is of comparatively recent date, the 
course is rapid, and the prognosis bad in proportion, (ii.) Is the cancerous 
cachexia established ? If so, then some complication may occur at any 
time, haemorrhage, septicaemia, thrombosis, or some other such grave con- 
dition with its dangers, (iii.) Are there any indications of embarrassment 
of the kidneys ? If so, an opinion as to the probable length of life of 
the patient cannot be too guarded. We have no means of ascertaining 
the exact extent of the changes which are bringing on uraemia, (iv.) The 



686 SYSTEM OF GYNAECOLOGY 

age of the patient has usually some relation to the rate of growth : the 
younger the patient the worse the prognosis. To this rule, however, the 
exceptions are numerous, (v.) Does the patient take nourishment to 
the average amount in such cases ? It is obvious that if no specially 
threatening complication exist, the fatal end from marasmus must be 
hastened or delayed according to the patient's power of assimilating food, 
(vi.) Can the parts be kept in a tolerably aseptic condition ? If there be 
a cavity in the cervix, and if the body of the uterus and the vagina be not 
involved, the ulceration, and consequently the sapraemia, can be modified. 
In some cases, owing to descending growths in the vagina, the chief seat 
of the disease cannot be reached. The success of some of the palliative 
methods of treatment shows that the progress of the disease can be 
greatly modified by the use of the curette and antiseptics. 

Treatment of Cancer of the Portio Vaginalis and Cervix Uteri. — When 
a disease of the uterus is diagnosed as malignant, the question at once 
arises : Is it operable or inoperable ? 

If in a case of cancer of the portio or cervix the uterus is quite mova- 
ble, and on examination it is found that no considerable invasion of the 
broad ligament or sacro-uterine folds has occurred, then the treatment 
in our present state of knowledge is radical operation. 

If there is lymphatic infection, and considerable or complete fixation 
of the uterus, the case belongs to the inoperable class. 

Even when the uterus itself is in a condition to make operation other- 
wise feasible there may be some local complication or some general con- 
dition to make the radical operation unjustifiable. 

In all ox)erable cases the first question to be answered is whether 
total extirpation per vaginam be not the best method of treatment. 

Total Extirpation of the Uterus. — The operation may be undertaken 
at one or other of two stages in the development of the disease. In the 
first place, the object sought is the entire ablation of the affected organ, 
including surrounding portions of vagina and parametrium which show 
no trace of invasion by the disease. The tissue operated upon must be 
sound throughout. Such are the cases in which, when the operation is 
performed at a very early stage, and the patient survives the danger 
of the surgical procedure, there is ground for confident hope that she 
is permanently relieved of her troubles. 

In the second place, the operation may be undertaken with advantage 
even if there be some slight interference with the movements of the 
uterus, and the broad ligaments or sacro-uterine folds can be felt to be 
more prominent and better defined than in perfect health. In such cases 
there is some additional difficulty in the early stages of the operation ; 
but the remote results are so satisfactory as not only to justify, but 
to demand operative treatment. There is little ground for expecting a 
permanent cure in such cases. The disease will recur at a more or less 
remote date, but the immediate advantages to the patient, and the diminu- 
tion in the sufferings of the late stage of the disease, when recurrence 
has taken place, are such as greatly to outweigh the danger and distress 



MALIGNANT DISEASES OF THE UTERUS 687 

of operation. These are usually cases in which, owing to delay on the 
patient's part in seeking medical advice, or owing to want of promptness 
and precision in diagnosis on the part of the practitioner, the disease has 
been allowed to make considerable progress. The vaginal portion may 
have assumed the condition of a large hypertrophic and superficially 
ulcerating mass ; or it may have almost completely disappeared owing to 
the progress of ulceration within the cervical canal, and yet the uterus may 
not be completely fixed. There may be obvious indications of deterioration 
in the patient's general health owing to heemorrhage and other discharges, 
and the inability to take sufficient nourishment. The sanious or turbid 
serous discharge may have become so profuse and offensive as to be a source 
of distress to the patient ; but while the pain is still inconsiderable, and the 
movements of the uterus are but just appreciably embarrassed, there is 
every reason to expect a favourable result from radical surgical treatment. 
When vaginal extirpation has been decided upon, whatever the modi- 
fication of the operation, the necessary instruments and appliances are 
for the most part the same. The patient, after being anaesthetised, is 
placed in the lithotomy position with the liips projecting over the mar- 
gin of a suitable operating table. The uterus is, in my experience, best 
exposed by the use of Auvard's weighted speculum with a comparatively 
short blade. As the instrument is self-retaining, it releases the hand of 
an assistant for other purposes, and in this respect it is greatly superior to 
the short and broad speculum which was formerly, or may be still, in gen- 
eral use in Germany. Whatever measures may have been previously 
adopted to cleanse and disinfect the parts, it is now advisable to cleanse 
them thoroughly once more before making any incision or wound. Some 
operators insist upon the preliminary use of the curette and cautery as 
essential. The anterior lip of the vaginal portion, where the tissue is 
healthy, should be seized with a suitable volsella and the movements of 
the uterus finally tested. The use of the volsella also enables the opera- 
tor to convey any necessary movements to the projecting vaginal portion 
so as to permit him thoroughly to cleanse the parts. The cleansing may 
be very well effected by thoroughly swabbing and rubbing the parts with 
dossils of cotton wool soaked in a solution of perchloride of mercury of 
1 in 2000. Xot only the uterus and vagina should be thus thoroughly 
washed, but all the external parts also, from the mons veneris downwards ; 
special attention being given to the folds of the labia, both minor and 
major. If there be any friable material about the ulcer or growth of the 
cervix, such shreds of tissue must be thoroughly disinfected and rubbed 
away by means of the swabs. It may be even advisable to use the 
curette, but such a proceeding is seldom necessary. If the disease have 
assumed the hypertrophic form it may be necessary to begin by rapidly 
cutting away with scissors sufficient of the new growth to make room for 
manipulation and to disembarrass the proceedings ; the bleeding vessels 
being rapidly seized by suitable pressure forceps. This preliminary step 
is almost always necessary in dealing with operable cases of cauliflower 
excrescence. In the majority of cases, however, it is usually practicable, 



688 SYSTEM OF GYNECOLOGY 

andj if so, preferable to proceed until the uterine arteries have been 
ligated, and the vagina and the lower portion of the parametrium cut, 
before removing any embarrassing mass ; as it can then be cut away 
without any considerable haemorrhage. Before beginning with scalpel 
or scissors it is advisable to ascertain the relations of the bladder to the 
cervix, and this is done by a suitable sound. 

There are many modifications of the beginning, and of every sepa- 
rate successive stage of the operation of vaginal hysterectomy. Every 
operator appears to have a method of his own. In my opinion, it is best 
to begin with the anterior vaginal wall, just w^here the vagina is reflected 
off the vaginal portion, if the tissue be so thoroughly healthy that a 
margin of normal vagina can be removed with the uterus. The ligatures 
should be used throughout in order to prevent the loss of blood which 
results from simple incision, for the patient is usually .anaemic. To 
economise time a special needle may be used for the proper placing 
of the ligatures. It consists of a strong metal instrument, shaped 
like an aneurysm needle but without eye, and with a point like a blunt 
Hagedorn needle. There is a notch for catching the ligature not far 
from the point on the convexity of the rim. The instrument should be 
short and strong. 

While the uterus is firmly dragged upon by means of a suitable 
volsella, and held steady by an assistant, the operator passes the needle 
transversely through a considerable portion of the healthy anterior vaginal 
wall, so as to occupy as nearly as possible the central third. An assistant 
puts the loop of suitable silk ligature into the notch of the needle, the 
needle is drawn back, and the ligature, thus brought through, is tied by 
the operator. The uncut ends can now be held up by one of the 
assistants, and the silk acts to some extent as a retractor. The vagina 
is cut through with scalpel or scissors so as to leave a sufficient button 
held by the ligature. Care should now be taken to ascertain that the fin- 
ger nail or the handle of the scalpel can be passed into the cellular tissue 
between the vagina and uterus. A portion of the vagina should again be 
taken up on each side in the same way, and cut as before, the separation 
of the vaginal wall and uterus being carried laterally by breaking down 
the loose tissue with the index finger, or suitable implement. In patients 
who are not anaemic a little time is saved by cutting through this portion 
of vagina, by scalpel or scissors, without previous ligation. The uterus is 
now drawn sideways — say towards the left — in order to secure the para- 
metrium on the right side, including the uterine vessels. Here it is usually 
advisable to employ a retractor to prevent the side of the vagina and the 
labium from obscuring the field of operation. The needle is now passed 
well down into the parametrium, beginning at the angle of the portion of 
the vagina already cut, and coming out symmetrically at the correspond- 
ing point posteriorly. If care be taken to keep close to the uterus, while 
at the same time the needle is brought out through sound vaginal tissue 
posteriorly, then the ligature which has thus been introduced may be 
tied, and the vagina and parametrium cut through, to the extent of the 



MALIGNANT DISEASES OF THE UTERUS 6S9 

tissues ligated, with, precision and confidence. The same proceeding is 
carried out on the opposite side. The uterus in a suitable case may now 
be dragged much lower, and the complete separation of the cervix from 
the bladder should be carried out by carefully working with the tip of 
the index finger from the middle line towards each side. The colour 
and the firmness of the uterine tissue should not leave the operator in 
doubt whether he has hit upon the cellular tissue at the proper depth. 
Before the peritoneum of the vesico-uterine fold is cut through the 
parts should be thoroughly examined for bleeding points, and all 
haemorrhage suppressed by suitable means. It may be necessary to use 
ligatures or pressure forceps temporarily. It seems to me a prefera- 
ble rule to open into the peritoneum anteriorly, rather than to cut 
first into Douglas' space. The anterior fold is easily opened by tear- 
ing or cutting at the stage of the operation now reached, and a sponge 
of suitable size with a piece of silk thread or silver wire attached (so 
as to prevent it from being lost amongst the intestines), is passed through 
the opening. It is now time to open Douglas' space. The posterior 
vaginal wall is ligated and cut through in the same way as before. 
Whether the anterior vaginal wall be ligated before cutting, or be merely 
incised, it is always advisable to tie, and then to cut the posterior vaginal 
wall in sections, or to use pressure forceps, as it is so much more vascular 
than the anterior wall. The cellular tissue is then broken down as far up- 
ward as possible upon the posterior surface of the cervix before tearing 
through or cutting the peritoneum. The deeper the cellular tissue can be 
torn before the peritoneum is cut the broader is the future healing surface 
obtained. An opening is made through the peritoneum and extended later- 
allj^, and a sponge is passed through as in front. The uterus is now sepa- 
rated from all the structures around it with the exceptions of portions of 
the two broad ligaments. This is the stage at which the clamp is put on by 
those who prefer the clamp. If the uterus be considerably enlarged, it may 
be necessary to use more than one clamp on each side. "When the clamp 
is secured the broad ligament is cut through on each side, leaving sulficient 
tissue for the clamp to maintain its hold. Then the uterus is drawn 
out. AVhen the ligature is used the needle is made to mark off a suita- 
ble amount of tissue in the remainder of a broad ligament ; the liga- 
ture is drawn through and tied firmly, the ends being left long. This 
is repeated in stages upwards through the whole of the broad ligament 
and over the Fallopian tube and ovarian ligament ; and the same thing 
is repeated on the opposite side. When the uterus is drawn away the 
stumps of the broad ligaments are seen on either side, and the sponges 
are in the middle line retaining the intestines and omentum in the pelvis. 
The sponges may or may not be renewed, according to the amount of 
manipulation that has been necessary, and of the haemorrhage that has 
occurred ; but it is best upon the whole to renew them, so as to ascertain 
whether haemorrhage is going on from any point. At this stage in the 
operation the danger of prolapse of intestine or omentum should always 
be guarded against. If the patient is allowed to strain from sickness 

2 Y 



690 SYSTEM OF GYNECOLOGY 

there is a real danger to life from dislocation of bowel, wliicb. may end 
in obstruction. 

The question always arises: Should the ovaries be removed or left? 
As they are seldom or never infected in any way by the disease, it is 
not worth while to complicate the operation by removing them unless 
they force themselves upon the operator's notice by becoming pro- 
lapsed. If the patient has passed the menopause the ovaries are shriv- 
elled and atrophic ; and if she is comparatively young they soon waste 
owing to the distal ligation of their arteries. 

An important modification has now to be considered. Should the 
operation be completed by merely packing in iodoform gauze or other 
suitable material to close the chasm in the pelvic floor, or should the 
great wound be closed by sutures ? From my early experience of the 
occurrence of dislocation of intestine and consequent fatal obstruction, 
and of the occurrence of the distressing but not necessarily fatal com- 
plication of vesical fistula, I believe it is decidedly the best practice to 
close the wound. The proceeding is of the same kind as the introduc- 
tion of the sutures through the abdominal parietes in closing the wound 
in abdominal section. Fairly strong catgut or fine silk may be passed 
by means of a suitable needle through the anterior vaginal wall, very 
superficially through the raw surface of connective tissue, and then 
through the torn anterior peritoneum; a good hold being taken of 
vagina and peritoneum. The needle is then passed posteriorly through 
the peritoneum, which has formed part of the floor of Douglas' space, 
and finally through the posterior vaginal wall. The whole chasm in 
the pelvic floor may be thus closed, with the exception of the two ex- 
tremities through which the long ends of the ligatures of the broad 
ligament pass. These ligatures may be conveniently twisted into a 
cord at each end, and held out of the field of operation. 

After Olshausen's success in completing the operation by cutting 
short the broad ligament ligatures, and completely closing the wound in 
the pelvis, I tried for a time to do without drainage, but found the result 
unsatisfactory. Several times, owing to unfavourable symptoms which 
followed, it was necessary to undo some stitches in order to permit of 
the escape of retained fluid; since then I have always used at least 
one drain of perforated and carefully prepared rubber tubing, which is 
inserted into one or other extremity of the wound. After the with- 
drawal of the sponges a final swabbing of the ligatures, and of the 
vaginal pocket which is formed when the sutures are drawn tight and 
tied, is now all that is necessary before applying iodoform and iodoform 
gauze sufficient to support the pelvic floor and to act as a drain. It is 
not advisable, from the unfounded fear of prolapse, to pack the vagina 
very tight with the gauze. In one case, at least, I have seen very distress- 
ing symptoms immediately following the operation, symptoms so severe 
as to suggest intestinal obstruction, immediately relieved by removal of 
the vaginal tampon. If the ligatures are sufficient in number and firmly 
tied, there should be no anxiety about primary or secondary haemorrhage. 



MALIGNANT DISEASES OF THE UTERUS 691 

The after treatment is, as a rule, extremely simple : it is almost 
purely expectant. If the ligature has been used it is not necessary to 
interfere with the parts for several days. There may be at first con- 
siderable blood-staining on the external pad; if, however, there are 
no constitutional signs of haemorrhage, it is not advisable to undo the 
dressings. The application of the ice-bag in the iliac regions, the use, 
perhaps, of a hypogastric pad, and the administration of considerable 
quantities of warm neutral fluid, will almost certainly stop or make 
up for too profuse drainage. The pulse and temperature will indicate 
whether the progress is normal or whether complications threaten ; in 
most cases after the first day there is in the repose and absence of 
symptoms a suggestion of the normal puerperium. Septic peritonitis 
is the danger at this stage ; fortunately it is not common : when it 
does occur it may run a very rapid course in spite of irrigation and 
free drainage. 

In elderly subjects pain is not much complained of ; but in younger 
patients the lumbar pain may be excessively severe, and require the ad- 
ministration of morphia. There is no evidence that morphia does the 
patient any harm ; and there can hardly be a question whether the sur- 
geon be justified in leaving his patient to endure tortures which she was 
not led to anticipate when she assented to the operation. Whether mor- 
phia be administered or not, it is advisable to stimulate the peristaltic 
action of the intestines, in order to avoid, if possible, the principal dan- 
ger not yet passed ; namely, obstruction of the bowels. After thirty- 
six hours — when, if no adverse symptoms have arisen, one may say with 
confidence that the danger of septic peritonitis is over — the aperient may 
be administered. I prefer one-grain doses of calomel administered at 
intervals of an hour, and as many as five grains may be given in this 
way if no unfavourable symptoms a^ppear. If flatus now begins to pass 
freely with the aid of the rectum tube the danger of obstruction is also 
at an end. The aperient may be supplemented by the administration of 
a saline; and at this stage I have reason to prefer one or two drachms 
of the sulphate of magnesia made into a lemon syrup and administered 
warm. The drainage tabe is, as a rule, of no further use after the first 
three days, and it may be withdrawn. 

Towards the end of the first week there may be some suppuration ; 
and it is well, if this come on, to change the dressings every day, 
swabbing the parts well during the process with a warm antiseptic 
solution. In the second week the ligatures come away; occasionally 
it is advisable by traction to anticipate their spontaneous expulsion. 

There does not seem to be any danger of the occurrence of hernia 
owing to weakness of the pelvic floor; it would seem that after a very 
few days such adhesions are formed within the pelvis as to prevent any 
considerable force from acting on any one point in the cicatrising wound. 
Nevertheless, considering the need for every possible advantage of physi- 
cal and mental repose, with efiicient nourishment and the influence of the 
best sanitary conditions, I do not think we render our patients a good 



692 SYSTEM OF GYNECOLOGY 

service in hurrying tliem out of bed so that we may point to a " record " 
time of operation and convalescence. Most of our cases are hospital 
patients, and I always feel that the longer we can keep them and nurse 
them the less risk there is of the recurrence of the disease. 

So numerous are the modifications of this operation, that it might 
almost be said with literal truth that each operator who has done any 
considerable number of operations has called attention to the advan- 
tages of some modification of his own. 

The method of turning the uterus upside down, which was universal 
at first, is now given up. After partial division of the broad ligament 
on each side, the manipulations by the volsella were carried out until 
the fundus uteri could be seized and dragged down through either 
the anterior or posterior opening. The result of this manoeuvre was 
to twist the broad ligaments, which could then be tied in bulk. Its 
drawbacks soon became obvious enough. The method led more readily 
than almost any other to the ligation of the ureters, and owing to the 
mass of tissue tied, haemorrhage, from slipping of ligatures, was too fre- 
quent a result. Some slight modification of it, however, to meet special 
difficulties, may be still introduced during the operation. 

Among other modifications is that of Fritsch, who begins the opera- 
tion at the sides ; this enables him to tie the uterine vessels at a very 
early stage of the proceedings, and to diminish hsemorrhage. It is a 
modification which can, no doubt, be very readily applied to the less 
advanced cases. 

The thermo-cautery has been introduced by Sanger to divide the 
vagina all round so as to prevent haemorrhage, and to save the time 
otherwise required to introduce the ligatures. The advantages and 
drawbacks of the introduction of the thermo-cautery at this stage of 
the operation must be obvious to any one who has attempted to use it. 
Mackenrodt goes further still with the use of the cautery ; he has re- 
ported several cases in which he trusted to the use of the thermo-cautery 
to divide the tissues including vessels throughout the operation. He ap- 
pears to believe in it as a safe and effective method of operation, and he 
claims for it that recurrence by inoculation is less likely to take place. 

The clamp is, however, the principal modification in the operation of 
extirpation of the uterus. Its advantages are maintained mainly by 
Eichelot and Pean in France, by Landau and others in Germany. There 
are already many inventors of clamps for which special advantages are 
claimed, but at the present time it does not appear that the clamp opera- 
tion is making headway. The clamp certainly shortens the operation, 
and it is much easier with it than with the ligature to control haemor- 
rhage from infiltrated tissue. Some of the disadvantages of the clamp, 
however, are obvious enough. It prevents the closure of the wound in 
the pelvis ; that is to say, the completion of the operation. It involves 
danger of tearing through the tissues held by it, and consequently of 
producing haemorrhage. This must always be the case so long as any 
portion of the clamp remains external in the dressings. Then the 



MALIGNANT DISEASES OF THE UTERUS 693 

destruction of tissue by necrosis, and the interference with the dressings 
on removal of the clamp, must produce a distinct danger of septic in- 
fection. In some of the cases reported the intestine had been nipped 
by the point of the clamp, which was away beyond reach ; this is an 
accident that should hardly occur in the hands of a careful and experi- 
enced operator. To a different class of accidents belongs the catching of 
the ureters by the clamp, which is said to occur more frequently than in 
the ligature operation : in any case it is an accident which may occur 
in the hands of the most careful. 

Results of Total Extirpation per Vaginam. — So numerous and a'oIu- 
minous have been the publications dealing with the results of opera- 
tions for cancer of the uterus during the last few years, that one can 
only select a few reports as types of their class, in order to call attention 
to the practical conclusions which the perusal of many of them suggests. 

A few years ago, when the operation was just beginning to gain a 
footing in England, Dr. William Duncan called the attention of the 
medical profession to it. From his own experience, and the results culled 
from numerous publications, he came to the conclusion that the operation 
involved a mortality of 25 to 30 per cent. This discouraging result 
depended upon the fact that a large number of the operators had 
only one case to report. AYitli greater experience the results of the 
operation have marvellously improved; and they may be considered 
supremely satisfactory, even without applying the illusory or impossible 
standard of " the best results of the most experienced operators." 

If we analyse the report of Krukenberg already referred to, 
we find, during 5^ years ending April 1891, a very large propor- 
tion of the cases of malignant disease of the uterus were considered 
operable: 292 in 924, or 31-6 per cent. The 292 radical operations 
were made up in this proportion : 235 times vaginal hysterectomy, 44 
times supravaginal amputation, and 13 times supravaginal amputation 
after abdominal section. Of the radical operations, 197 were for cancer 
of the cervix, with the following results : 25 died directly in consequence 
of the operation, that is, 12-7 per cent. Eecurrence of the disease 
appeared in 69 within one year. Pyometra was the worst complication, 
nearly all the cases being fatal from infection. Nine of the patients 
were alive and well at the end of nine years. Important information 
bearing on prognosis is given regarding 48 cases which remained free 
from recurrence, and ob in which the disease had reappeared, (i.) Of cases 
of carcinoma of the mucosa of the cervix in the early stage, recurrence 
took place in 33-3 per cent, (ii.) Of cases of superficial ulceration of the 
portio, there was recurrence in 36*4 per cent, (iii.) Of small cauliflower 
excrescence, recurrence in 42-4 per cent, (iv.) Of advanced carcinoma of 
the cervical mucous membrane, recurrence in 58*8 per cent, (v.) Of 
carcinoma involving the walls of the cervix, recurrence in 60 per cent, 
(vi.) Of greatly developed cauliflower excrescence of the portio, recur- 
rence in 62-5 per cent, (vii.) Of deep ulceration of the cer\4x, begin- 
ning as epithelioma of the portio, recurrence in 80 per cent. 



694 SYSTEM OF GYNECOLOGY 

With regard to influences favouring recurrence nothing definite ap- 
pears from the figures except the site and extent of the disease. Upon 
the whole, women over 45 years of age showed less frequent recurrence 
than women under 45. 

Among figures for a period practically the same we have those of 
Terrier and Hartmann. In 36 cases there was a mortality from the 
operation equal to 23-5 per cent. Seven patients, at a sufficiently 
remote period, were considered permanently cured. They put down 
recurrences at 70 per cent, and cures at 30 per cent. 

Eichelot (38), publishing the results of four years' work in 1892, 
shows a greatly diminished mortality, the causes of which may be inferred 
from the facts. He performed 225 operations, with 11 deaths ; that is, 
5 per cent. He used the clamp exclusively, and argues in its favour. 
He had no haemorrhage either primary or secondary. He does not think 
the ureters are in greater danger from the clamp than from the ligature ; 
he never caught intestine with his instrument ; and he does not believe 
that the clamp narrows the field of operation. As a drawback he men- 
tions that the clamp is more painful to the patient. 

Btirkle, in an inaugural dissertation in 1892, gives a summary 
of the operations, mostly German, up to the date of publication. He 
mentions 273 operations of total extirpation with a mortality of 10 per 
cent. Among the causes of death were : septic peritonitis in 22 cases ; 
ileus in 2 cases ; and haemorrhage, pneumonia, and heart failure in one 
case each. Among the incidents of operation were : incision of vagina 
and perineum, 5 times ; pyosalpinx, 4 times ; pyometra, 17 tim^es with 
loss of 7 patients ; complications with myomata in 9 cases ; ovarian 
tumour of considerable size, in 5 cases; injury to the ureter in 4 cases. 

From an account of Kaltenbach's work at Halle, published by 
Bticheler, we see how improvement went on in method as well as in 
results. The chief modification in Kaltenbach's method was suturing of 
the peritoneum in the pelvis ; he also employed antiseptics in a very 
stringent fashion. The total number of operations was 159, and the 
mortality was at the rate of 3-9 per cent. This was by a long way 
the lowest mortality at the time of the completion of the work. Among 
the accidents in the course of operation were injury to the bladder, pro- 
ducing fistula ; injury to, or tying the ureters, and the production of a 
faecal fistula : once a sponge was left within the pelvis. The number 
of operations for cancer of the cervix was 134. There were free from 
recurrence at the time of publication, 19 ; and four had remained free 
for over three years, with fatal recurrence afterwards. The ligature 
was used exclusively in operation. 

In 1894, Abel of Berlin published a paper on total extirpation, 
which was chiefly an argument in favour of the clamp. He mentioned 
that he and Landau, who also uses the clamp exclusively, had a mortality 
of 5-4 per cent over a total material of 93 cases. 

Zweifel's mortality up to the same time was almost exactly 5 per cent, 

Mangiagalli has given an account of the immediate and remote 



MALIGNANT DISEASES OF THE UTERUS 695 

results of his operations with such comments and quotations that a 
summary of his contributions might completely serve our purpose. He 
gives an analysis of his cases according to site of the disease, the exten- 
sion of the disease, and the method of operating, whether by ligature 
with closure of wound, or without closure of wound, or by the clamp. 

For example : in carcinoma of the cervix : — 

Without diffusion to vagina, etc., 46 cases, 45 recoveries, 1 death, 
mortality 2-17. 

With diffusion to vagina, etc., 36 cases, 30 recoveries, 6 deaths, 
mortality 16-66. 

In his 1st class — operations by ligature without suture of the 
wound — there were 23 cases, 20 recoveries, 3 deaths, that is a mortality 
of 13-04 per cent. 

In the 2nd class — operations by ligature with suture of the pelvic 
wound — 40 cases, 38 recoveries, 2 deaths ; a mortality of 5 per cent. 

In the 3rd class — use of the clamp — 25 cases, 22 recoveries, 3 deaths, 
a mortality of 12 per cent. 

Mangiagalli concludes that the mortality from extirpation for cancer 
of the body is greater than for cancer of the cervix ; but his material is 
perhaps too small for generalisation. One conclusion brought out by 
his figures on which he lays much stress is : " The most important 
element in the prognosis of vaginal hysterectomy for cancer of the cer- 
vix is the extent of the diffusion to the vagina and parametrium." 

In discussing the remote results the author accepts provisionally the 
criticism that the disease may be considered cured if there be no recur- 
rence within two years ; and shows that, according to the way in which 
deductions were made, his results would be at the rate of 38 to 44 per 
cent of cures. The German operations selected show from 36 to 64 per 
cent of such cases. In many of the contributions on the subject of 
results there appears to be a tendency to hold a sort of inquest on every 
death, and to draw up percentages according to the verdicts obtained 
after explaining away the causes of death. 

Eichelot (39) gives the results of his operative work down to August 
1895. He published an account of 274 cases of vaginal hysterectomy 
dating to the end of 1893 with the results, namely — 

4-i cases of uterine cancer .... 3 deaths. 

61 ,, pelvic suppuration . . . 5 ,, 

126 ,, non-suppurative affection . . 5 ,, 

43 ,, uterine fibroma . . . 1 ?» 

The total mortality is 5-10 per cent. 

From the end of 1893 to the 1st of August 1895 he had performed 
202 additional operations : — 

14 cases of uterine cancer .... 3 deaths. 

66 ,, pelvic suppuration . . . 3 ,, 

89 ,, non-suppurative affection . . 2 ,, 

33 ,, uterine fibroma . . . 2 ,, 



696 SYSTEM OF GYNECOLOGY 

Still a total mortality of practically 5 per cent, but with a very high 
mortality for cancer operations. The figures for operations undertaken 
on other grounds are given to indicate how little inherent danger there 
may be in the operation itself ; any further remark would be irrelevant. 

After such statistics it is much of a drop to come to my own fig- 
ures. I began to operate early in the history of vaginal hysterectomy 
(September 1882), and I have operated when I anticipated an advantage 
for the patient, after allowing for risk, operative distress, and injury to 
the general health. My cases have consequently included a considerable 
proportion where some invasion of the vagina and parametrium existed. 
It is some comfort to find that others, witness Mangiagalli, have had even 
a higher mortality in such cases. The tendency of isolated operators is, 
I imagine, to try operation on cases too far advanced, in the hope of 
giving the patient a chance. It is only the close observation of recent 
years that has shown how futile such operative work must be. 

My first 10 cases were published in the Practitioner in 1889 ; 4 of 
the patients died, giving a mortality of 40 per cent. Up to the time of 
beginning to close the pelvic wound in 1890, I had operated another 12 
times with 1 death. 

From the time of closing the wound completely I had 2 deaths in 
1890, and so I began drainage as well as closure. From the time of 
drainage to the end of July 1894, there was a further series, making 45 
cases with 7 deaths, a mortality of 15 per cent. Up to that time also 
there were 15 private cases of cancer of the portio and cervix, with 1 
death, making a mortality of 6^ per cent. Partly before and partly 
since July 1894 there have been 5 cases of cancer of the body. All 
these patients recovered from the operation, and all, so far as is known, 
are still free from recurrence. 

Considering the physical wrecks some of the patients were at the 
time of operation, and the stage which the disease had reached, we can 
only wonder that even this modified success was achieved. The opera- 
tions are all given without deduction on account of any process of 
"inquest" on fatal cases. But for the operation no patient would 
have died at the time she did. 

Few cases .have been seen in the most favourable stage for operation, 
hence the frequency of recurrence has been disheartening. Such patients 
are difficult to trace, and I only know of two now alive and well who 
were operated on for cervix carcinoma before the autumn of 1890. 

Recurrence after 02:)eration. — Under the head of the course and 
symptoms of cancer of the vaginal portion and cervix, we may best con- 
sider the modes of recurrence after operation. In by far the greater 
number of operation cases it is the cervix, or part of it, which is affected ; 
and it is after operation for the malignant disease of the cervix that 
recurrence takes place in the vast majority of cases. 

For our present exact information on this subject we owe much to 
Winter (57), who carefully observed 59 cases of recurrence, and published 
the results obtained. He divided the cases observed into three classes : 



MALIGNANT DISEASES OF THE UTERUS 697 

(a) Recurrence by metastasis ; (h) Lymphatic recurrence ; and (c) Local 
recurrence ; that is, at the site of the wound. 

With regard to metastasis, all observers are agreed that it is not 
common as a result of uterine cancer. Gusserow summarised the 
opinions which prevailed before total extirpation of the uterus. Metas- 
tases, according to Blau and others, occurred in the liver in 9 per cent, 
in the lungs in 7 per cent, and in the kidneys in 3-5 per cent of the cases 
which ran their course. In women who have undergone the operation of 
total extirpation metastases are almost unknown. In 43 cases of recur- 
rence after operation, in which he made a post-mortem examination, 
Winter did not find a single case with metastasis. In 202 cases of 
recurrence only 9 were real examples of metastasis. Only 2-5 per cent 
of all women operated upon suffered from metastases, which occurred 
in the stomach, lungs, liver, and ovaries. 

Lymphatic recurrence is of more importance. From the cancer of 
the cervix the glands which become affected are the iliac ; these lie close 
to the sacro-iliac synchondrosis, just below the brim of the true pelvis, 
and at the point of division of the iliac and hj-pogastric arteries. From 
cancer of the body the lumbar glands are affected. These may develop 
into masses in which the aorta is embedded, and they may be felt high 
up in the abdomen. Occasionally by anastomosis the obturator and in- 
guinal glands become affected. Infection of the pelvic glands is not so 
common as we might expect ; and it occurs comparatively late. Blau 
and Dybowsky, on post-mortem examination in 203 cases, found infection 
of the glands only 40 times. Winter, in the post-mortem examinations 
of 43 women, who had undergone the total extirpation operation, found 
the glands involved only three times, and in only one case was the cancer 
confined to the uterus. In operable cases in clinical examination he 
found the glands infected three times ; when the parametrium was 
involved the glands Avere found to be infected in 24 per cent of the 
cases. Pure lymphatic recurrence is rare ; it is in conjunction with 
recurrence in the cicatrix that the glands are found most frequently 
affected. 

Local recurrence is by far the most frequent form. It occurs in 
the cicatrix, in the bladder, peritoneum, pelvic cellular tissue, and 
vagina. The most common cause of this relapse is without doubt the 
incomplete removal of the affected tissue at the operation. This recur- 
rence is then very early, as a rule. All observers agree that one chief 
cause of recurrence is permitting cancerous material to come in contact 
with the peritoneum or freshly wounded tissues. The disease is then an 
inoculation recurrence ; and this infection appears to take place only on 
account of that special state of health of the patient, Avhich made the 
original disease possible. The recurrence in the vagina has some points of 
interest of its own ; it must be a fresh development of the disease produced 
by prolonged contact of the cancerous growth with a surface not specially 
susceptible. The first time I saw this was in a ^^atient who underwent 
the total extirpation operation on account of cancer of the cervix which 



698 SYSTEM OF GYNECOLOGY 

had grown into a mushroom mass, lying in contact with the posterior 
vaginal wall. At the operation it was found that there was considerable 
vaginitis high up, and there was one spot in particular on the posterior 
wall with broken down epithelium. It was red and moist and sore-looking, 
but it was distinctly separated from the vaginal portion by a space of 
comparatively healthy tissue. Taking it for a vaginitis produced by the 
discharge, I did not entirely remove this affected portion of vagina, and 
was disappointed a few months later to find a new growth of epithelioma 
developing from the area which had apparently been the seat of an 
inflammatory affection only. 

Many such cases have been reported, and they go to prove the in- 
fectiousness of cancer by prolonged contact in suitable subjects. 

The study of recurrence leads at every point to important practical 
conclusions, especially with regard to the need for extreme care to pre- 
vent infection at the time of operation. 

Sacral Method. — The sacral method of operating with which the 
names of Kraske, Zuckerkandl, Hochenegg, and others are associated, 
has been practised a good deal in Germany, but has received little atten- 
tion in this country. The advantages originally claimed for it were the 
facility with which the field of operation could be reached and kept fully 
in view, and the widening of the scope of the total extirpation by 
sweeping away the affected parts more thoroughly than was practicable 
by the vagina. It is also said to be more suitable in cases of cancer 
of the body with enlargement of the uterus and senile narrowness of 
the vagina. With this indication Fritsch agrees. 

An obvious disadvantage is that it involves resection of part of the 
sacrum and consequently a prolonged convalescence. In some of the 
cases first reported the sacrum not only did not again unite, but even 
necrosed, with corresponding sloughing of connected soft parts. One 
such misadventure occurred to so experienced an operator as Hegar. 

Many proposals were consequently made for improving the operation, 
and perhaps as noticeable a modification as any was that proposed by 
Herzfeld (18). It is necessary, according to him, to resect the coccyx 
only, or at most about one centimetre of the lowest part of the sacrum in 
addition. An incision is made along the medium crest of the sacrum, and 
carried in a slight curve to the periphery of the anus on the right side. 
The recto-vaginal sej^tum is then easily found, and the deeper parts are 
separated with the finger tip or handle of the scalpel. The prevertebral 
fascia is thus brought into view, and is cut through along the right margin 
of the rectum. Herzfeld claims for this detail in the operation that the 
rectum does not come in the way, and it is more easy to reach the pos- 
terior surface of the vagina which can be drawn to the right. The vagina 
is easily distinguished by its whiter appearance. Between the right 
margin of the rectum and the point of the posterior vaginal wall the 
lowest portion of Douglas' space is sure to be found. Some recent 
critics of the operation say that they have met with considerable diflS.- 
culty here. 



MALIGNANT DISEASES OF THE UTERUS 699 

Herzfeld takes the plica transversalis recti as a landmark, and can 
with confidence open Douglas' space on the right margin of the rectum 
at this point. The wound is cautiously extended, and then the uterus 
with its adnexa can be drawn through in such a way that its anterior 
surface now looks upwards and backwards. On this surface the line of 
reflection of the vesico-uterine fold of peritoneum can be distinctly seen. 
This portion of peritoneum is cut through, and the uterus is then sepa- 
rated from the bladder down to the anterior insertion of the vagina. The 
left broad ligament is now dragged upon, ligatured and cut, and after this 
the peritoneal opening is completely closed with sutures which bring 
together the posterior margin of the peritoneum in Douglas' space, and 
the cut margin of the vesico-uterine fold. The rest of the operation, 
which involves manipulation of the cancer, is entirely extraperitoneal. 
It is claimed as an advantage for this proceeding, that it prevents 
infection of the peritoneum by cancer juice or cancer elements, and 
thus helps to prevent the recurrence of the disease. 

The broad ligaments are now tied in sections and cut downwards to 
the portio vaginalis. It is said that during these proceedings the vessels 
and ureters can be distinctly seen and properly dealt with. The posterior 
wall of the vagina is finally cut through and, when the incision has been 
carried round, the uterus can be removed. It is claimed for the opera- 
tion that the ligatures can be placed upon the broad ligaments as far 
outwards from the uterus as may be necessary, and the vagina, if affected, 
can easily be resected to any required extent. 

The upper opening of the vagina may now be closed with sutures, 
and drainage effected through the original wound made in gaining access 
to the field of operation ; or the wound may be closed and the vagina be 
left open for drainage. The latter course was suggested by Schauta, 
and appears to be preferable. 

The author of this superior modification of the sacral method admits 
that it does not extend the scope of the operation, inasmuch as when the 
parametrium is involved it gives no better results than any other method 
of surgical treatment. What is said of it by the most reasonable and 
most highly qualified of critics may be best stated in a summary of Von 
Winckel's remarks on the subject. He had done the operation in a suit- 
able case, and in doing so had observed some points which he had not 
previously heard anything about. He had to dissect higher up than he 
had been led to expect. When the fascia was cut through air rushed in 
and pushed all the parts to the left ; this caused considerable delay, and 
consequently more loss of blood than is usual in the vaginal operation. 
The separation of the left side of the uterus and its ligation was extremely 
difficult. As to the ureters, he could not find them at all, although he 
searched for them ; and he is sure that in this operation they are not 
more easily avoided than in the vaginal operation. The result of the 
operation was unsatisfactory : the vagina became fixed above, and sutures 
were expelled through it ; a fistula formed in communication with the 
bone, small spicules of bone continued to be shed for months afterwards, 



700 SYSTEM OF GYNECOLOGY 

and the convalescence was very slow. His conclusion is that if by so 
radical an operation we can obtain no better result than by means of 
the curette or the cautery, we are bound to tell the patient frankly that 
we can promise nothing better, and to let total extirpation alone. 

Eecent reports suggest that some Continental gynaecologists have 
taken this advice to heart. 

FreuncVs Operation. — After the first dubious successes of Langen- 
beck, Blundell, and Eecamier, in vaginal hysterectomy for cancer, early 
in the present century, all radical operations were given up for about 
forty years. In 1878 Freund, of Strassburg, performed the first suc- 
cessful operation with which his name is associated. It consisted of a 
vaginal and an abdominal operation ; and in spite of the tedious details 
which it involved, and its technical difficulties, it was performed by 
many gynaecologists in Germany and elsewhere in Europe, and by a few 
in England. The eagerness with which it was adopted is in some degree 
a sign of the conscious helplessness of surgery in dealing with uterine 
cancer at that time. 

It was soon discovered to be a very fatal operation, and many modifi- 
cations were soon introduced in the hope of diminishing the mortality, 
but with only slight success. The dangers consisted chiefly in the shock 
from long exposure and manipulation of the bowels, obstruction from 
paralysis of the intestines, haemorrhage, infection from the cancerous 
elements, peritonitis, and injuries to the ureters and bladder. Modifica- 
tions were carried to the extent of dividing the recti muscles, and even 
of resecting the anterior pelvic wall. The danger is indicated by the 
statistics of the early period of the operation collected by C. von Eokit- 
ansky. Of ninety-five women operated upon, sixty-five died directly 
from the effects of the operation ; and in all the remaining cases the 
disease soon recurred. 

It may be said that the operation has been abandoned except to meet 
a certain comparatively rare combination of circumstances, as in cancer 
with myoma or in large sarcoma of the uterus. There is, perhaps, quite 
recently a disposition to give the operation more attention, since such 
satisfactory results have been obtained in the similar operation for 
fibromyoma of the uterus. 

H. W. Freund (9), who may naturally be disposed to think well of 
the operation, recently gave the results up to date (from 1886) as show- 
ing a mortality of 33 per cent in twenty-seven cases. Up to 1886 the 
mortality for all the cases collected was 67 per cent. In ten recent 
cases at the Strassburg Hospital there were two deaths from the opera- 
tion, and two more within a few weeks. 

The technique of the operation, with all improvements as now per- 
formed at Strassburg, is shortly as follows : The patient is put on the 
table, and the pelvis raised into the high position (Beckenhochlagerung) 
by means of a suitable pad placed under the hips. The vaginal Avail is 
incised round the portio vaginalis; Douglas' space is opened as com- 
pletely as possible, and a sponge is pushed through the opening. A 



MALIGNANT DISEASES OF THE UTERUS 701 

suitable hydrostatic dilator or bag is introduced into the vagina and 
made as tense as possible; by this means the uterus is raised out of the 
pelvis, and thus the abdominal part of the operation is much facilitated. 
When the abdominal cavity has been opened by a full incision the ^jro- 
cess of separating the bladder from the uterus is at once begun, and is 
easily completed with the guidance of a sound. The old practices of 
drawing out the intestines and distending the bladder have been given 
up. The appendages and the broad ligaments are tied in sections and 
cut through on each side as in the ordinary operation; and owing to 
recent modifications this part of the operation is remarkabl}^ easy. The 
ligatures of the broad ligament, which are left long, are now drawn down 
through the vagina ; and the anterior and posterior cut margins of the 
peritoneum are brought together Avith sutures. The peritoneal cavity 
may be completely shut off from the vagina, or a sufficient opening left 
for drainage. 

Partial Extirpation. — The operation which is the rival or alternative 
to total extirpation is not any one of the modifications mentioned, but 
partial extirpation, or high amputation of the uterus. This operation was 
the first great step in advance, in the surgical treatment of uterine cancer, 
beyond the futile and sometimes injurious measures formerly in vogue, 
such as the application of caustics or escharotics, and the use of the chain 
ecraseur or the galvanic ecraseur. There can be no doubt that excellent 
results Avere obtained by the partial extirpation of the uterus, and some 
able, experienced, and conscientious gynaecologists still maintain that it 
is the best operation, and endeavour to restrict total extirpation within 
the narrowest possible limits. But even its strongest advocates have to 
admit that it is losing ground. One of these (08) begins his advocacy of 
the partial operation as follows : — "The total extirpation of the uterus 
per vaginam has become more and more the favourite operation of the 
German gynaecologists. The safe and even elegant technique, the brill- 
iant results, and the permanent success are constantly adding to the 
number of those who speak well of it. The foreign gynaecologists gradu- 
ally follow the lead of Germany, so that now scarcely an opponent of 
the operation may be said to exist. Schroeder's operation of amputation 
of the cervix for cancer of the portio vaginalis has become so completely 
obsolete that it is scarcely ever referred to iu works on total extirpation, 
much less brought into comparison with it." 

The introduction of the operation of partial extirpation of the uterus 
is usually attributed to Schroeder, who continued to practise it after most 
of his contemporaries had declared for total extirpation. The practice 
and advocacy of the operation appear to have been carried on mainly by 
Hofmeier, Winter, and other pupils. In this country Sir John Williams 
has been the chief advocate of partial extirpation ; in fact, the portion 
of his work which he devotes to the surgical treatment of cancer of 
the uterus is largely an effort to prove that, in cancer of the portio 
vaginalis and of the cervix, total extirpation of the uterus possesses no 
advantages over supravaginal amputation of the cervix. He endeavours 



702 SYSTEM OF GYNECOLOGY 

to establish his proof by evidence from pathology and from clinical 
experience. 

The argument from pathology depends almost entirely upon the 
belief that cancer of the cervix begins in certain situations, and has a 
tendency to grow downwards or outwards towards the parametric con- 
nective tissue. This is not the place to go into controversial details, 
but it may be stated with confidence that more recent observations lead 
to the conclusion that the views stated are not consonant with the 
facts, and therefore the argument for partial amputation, so far as it 
depends upon the facts, entirely fails. 

With regard to what may be called the clinical argument, Sir John 
Williams asks : What does the experience of operators tell us on the 
subject ? A good deal has happened since Cancer of the Uterus was pub- 
lished in 1888, and the views of some experienced operators may be in- 
ferred from the language used by Winter three years later. At a time 
when total extirpation was looked upon as a formidable and dangerous 
operation it was natural enough to endeavour to make the most of the 
partial operation ; but it has been proved by the results of operators 
within the last few years, that total extirpation is not necessarily a more 
dangerous operation than supravaginal amputation. On the relative fre- 
quency of recurrence after the two operations, and the comparative length 
of time of immunity, no satisfactory conclusion can be drawn from such 
arguments. It is almost invariably a comparison of unlike things, because 
the operation of partial extirpation was reserved for the most favourable 
cases ; it was only when the disease was more advanced that total extir- 
pation was attempted by the early operators. Considering the improve- 
ment in the technique of the operation, and the encouraging results of 
the most experienced operators, who deal with all cases by total extir- 
pation, the advantages appear now to be almost entirely on the side of 
total extirpation. 

The object of the partial operation is to operate within healthy tissue 
in the parametrium, and to reach up as high as possible without opening 
the peritoneum. It is claimed for the operation that it is comparatively 
easy of performance ; that there is little shock ; that the field of opera- 
tion is entirely within the operator's view and control, and that ileus 
and peritonitis are avoided. One advocate, at least, of the supravaginal 
amputation seriously states, as a point in favour of partial operation, 
that a woman may become pregnant and even go to full term after having 
the cervix uteri removed for cancer, and he produces several cases from 
the literature of the subject. He is able to show also, although our at- 
tention is not specially drawn to the fact, that some of these women who 
became pregnant soon lost their lives from recurrence and rapid growth 
of the disease. Women before the menopause are liable after high ampu- 
tation to cicatricial contraction of the lumen of the uterine canal, and 
to constant sufferings dependent upon that fact. The avoidance of so 
grave a result of the operation is in itself a very strong ground for pro- 
ceeding to total extirpation. In favour also of total extirpation is the 



MALIGNANT DISEASES OF THE UTERUS 703 

fact that we can never be certain of the extent of the diseased tissues. 
Many cases are reported in the literature of the subject, and I have 
myself seen several, in which there were distinct centres of develop- 
ment of the malignant disease; and consequently partial extirpation 
would have been a useless operation. Then again, in the partial opera- 
tion there is a much larger, and a less completely finished wound than 
in the complete operation ; so that, with an extensive surface which 
should granulate, there is probably more danger of parametritis and 
diffusion of the cancer than there is when the broad ligaments are 
efficiently ligated, and both blood-vessels and lymphatic channels are 
almost completely cut off. 

After all operations for cancer of the uterus, the recurrence takes 
place most frequently in the site of the wound, and in women who are 
still menstruating it stands to reason that recurrence is less likely to 
take place when quiescence of the parts is brought about by the com- 
plete oi3eration. The ebb and flow of menstruation, and the influence 
of blood-supply on the nervous system of the parts by emotional condi- 
tions in the ante-climacteric age, are much more likely to bring about 
recurrence than when, by complete removal of the uterus, and perhaps 
of the ovaries as well, the menopause is prematurely brought on. 

It seems to me that there is only one clearly definite class of case 
of cancer of the portio vaginalis in which partial operation may be the 
best operation ; that is in elderly or old women, in whom the disease is 
very slowly developing, and in whom the uterus is perfectly movable, 
and the vagina narrow and senile. 

With regard to the technique of the operation it is hardly neces- 
sary to go into details. It is really almost invariably identical with 
the first stages of the complete operation. One point in the operation, 
which should be considered essential, is the timely shutting off of the 
blood-supply by the uterine arteries ; after that is done the separation 
of the cervix from its surrounding structures and its amputation are 
comparatively easy proceedings, unembarrassed by any considerable 
amount of haemorrhage. 

Palliative Operations. — When the cancer is too far advanced for 
any radical operation the question always arises whether any benefit 
at all can be conferred by local treatment. The patient has reached the 
stage at which symptoms have to be treated as they appear ; but such 
treatment is dreary and unsatisfactory work, and every available means 
should be brought into use which offer any reasonable ground for the 
expectation of benefit. In a considerable proportion of the advanced 
cases there is a deep ulcerating cavity which may contain spongy debris, 
the result of the necrosis of the uterine tissues. In such cases there is 
a foul and copious discharge with intermittent attacks of hsemorrhage. 
These are the cases in which the sapraemic process at work is also doing 
the most harm in sapping the patient's strength. What means of local 
treatment worth employing have we at our disposal ? 

1. The sharp curette is naturally placed first; whether it be used 



704 SYSTEM OF GYNECOLOGY 

alone or supplemented by some chemical agent to destroy the infected 
tissues further. 

In such patients we cannot use the curette efficiently without the aid 
of an ansesthetic. Yet when there are grave objections to the administra- 
tion of chloroform or ether, the operation may still be carried out more 
or less completely without inflicting much pain. In such cases I have 
found it of great advantage, about an hour before the time appointed for 
operating, to give a considerable hypodermic injection of morphia; and 
just a few minutes before beginning a fair dose of whisky or brandy well 
diluted. When these medicines have taken effect it is wonderful how well 
the patient can bear even a tolerably thorough use of the instrument. 

In an ordinary case, when the patient has been put under the 
anaesthetic, it is best to place her on a table in a good light, and 
proceed with all the care as to detail and all the circumstance of an 
important operation. The reason why so many private patients are 
treated so inefficiently as compared with our hospital cases is largely, 
I believe, because we give too much heed to paltry objections to ex- 
posure, to the use of an operating table, and so forth. The patient is 
placed in the lithotomy position, and the parts are thoroughly brought 
into view with the aid of the weighted speculum. The uterus and 
vagina are thoroughly swabbed with a solution of mercury which helps 
to deodorise as well, and the uterus is, if necessary, steadied with a 
volsella. The broken down tissue is then rapidly swept away, and 
everj^ portion of the cavity is carefully gone over in detail until the 
instrument is felt to rasp upon firm tissue. It is occasionally neces- 
sary to cut away tags of comparatively healthy material, chiefly at the 
margins of the ulcer. The cavity is frequently swabbed with cotton 
wool soaked in mercury solution, and is finally packed with gauze or 
lint wrung out of the same solution. 

Such an operation has its uses in stopping haemorrhage and foul 
discharge for a time, but only comparatively slight and evanescent 
effects are to be expected from it. 

If the curette be worth using, its action should be supplemented by 
an escharotic ; and of all the substances available at present there can 
be little question that zinc chloride is the best. It should be put ready 
beforehand to apply immediately after the curetting, and it should be 
in the strongest manageable form. A solution of one in two or three, 
or a paste of equal parts of the chemical and moist flour, answers very 
well. It may be applied advantageously on the end of a shred of lint 
like a narrow bandage, the dry portion being packed in after, so as to 
keep the active agent in its place. Every care should be taken, by 
pledgets of cotton wool or lint soaked in a strong solution of soda 
bicarbonate, to protect the vagina from any surplus zinc salt. It is a 
good plan to finish by packing the vagina with a tampon consisting of 
a long strip of lint soaked in a strong solution of soda. This tampon 
may be left for a day or even for two days ; it is then removed and an 
antiseptic douche copiously used. 



MALIGNANT DISEASES OF THE UTERUS 705 

There are many other methods of employing this treatment, but 
there is no difference in essential details. From very considerable 
experience I can speak well of the method here described. 

The eschar keeps coming away in shreds or in liquid under the use 
of the douche for a week or so. During this time, and it may be for 
long afterwards, a marked change for the better takes place in the 
patient. The saprsemic temperature goes down ; she is comparatively 
free from pain ; the haemorrhage ceases ; the discharge is greatly modi- 
fied in many respects, and is almost free from smell ; the cavity ma}^ 
take on the appearance of a healthy granulating surface, covered with 
a thin mattery discharge. Later, the cavit^^ gradually contracts, cica- 
tricial tissue forms, and the improvement may last for many months. 
Meanwhile the patient becomes stronger. She puts on flesh, and loses 
in a great measure the anaemic or cachectic appearance. 

Some one or other of the above palliative operations may be used 
repeatedly with advantage when haemorrhage and foul-smelling discharge 
show that the ulceration is making progress. 

It has been raised as an objection to the curette that there is danger 
of perforating the uterus, and some cases have been reported in which 
this "accident" has occurred. But the same kind of objection might 
be made to many of our most useful medical and surgical means of com- 
bating disease. Some drugs are powerful poisons, and all scalpels should 
be sharp. Two conditions are required for the successful use of the 
curette : the case selected for treatment must be suitable, and the instru- 
ment must be used with reasonable care and skill. When so employed 
the curette is one of the most useful instruments the gynaecologist has 
at his command. 

The curette does sometimes cause considerable haemorrhage which is 
not easily stopped. It is occasionally necessary to use a very firm 
tampon and even counterpressure from above the pubes before it ceases. 
But as a rule the amount of bleeding is very slight, and the oozing ceases 
at once on the introduction of the tampon with zinc solution. 

A more valid objection is the fear of too extensive an action of the 
zinc chloride upon the tissues. This objection applies to nitric acid, 
and to other less manageable and less useful chemicals which have been 
used for the same purpose. If care be taken to ascertain the depth of 
uterine tissue between the ulcer and the peritoneum, and due allowance 
be made, the danger is reduced to the minimum ; and the result may 
fall little, if at all, short of that obtained by supravaginal amputation. 

The chemical substances which are occasionally applied, alone or 
in supplement to the curette — such as lunar caustic, iodine solution, 
bromine, sulphate of copper, solution of the perchloride of iron, and so 
forth — ought all to be discarded. They are difficult to control, and are 
consequently liable to cause injury to healthy parts ; or they may pro- 
duce discoloration of the tissues and an ambiguous state of the infected 
area, an ambiguity as likely as not to be cleared uj) in the revelations 
of an increased rate of growth due to the irritation. 

2z 



7o6 SYSTEM OF GYNECOLOGY 

2. Tim Cautery. — The use of the cautery is one of the best methods 
of dealing with inoperable cases of cancer of the uterus. It appears 
to be a special favourite in German Kliniks ; but it has not hitherto 
received the attention in this country which perhaps it deserves. One 
of the difficulties we have to meet in the efficient use of the cautery is 
to find a suitable instrument. The ordinary cautery, prepared to a white 
heat and then applied when it is getting dull, is theoretically one of the 
best ; but, unfortunately, in practice it invariably gets cooled down too 
rapidly, and it is necessary to wait, with the patient under the anaes- 
thetic, until the instrument is again heated ; or to keep a series of the 
instruments hot and use them at intervals. The same objection applies 
very largely to Pacquelin's cautery. It is applied apparently in perfect 
order, but it is liable to be cooled down by the blood, and time is lost 
in again reheating it ; at least, such is my experience of the use of the 
cautery in this operation. 

One of the most effective forms of cautery is the galvanic, which 
consists of a suitable stem for application, with means for turning on 
and interrupting the current ; the effective part of it consists of a porce- 
lain button surrounded and covered with platinum wire which is con- 
nected with the battery. This cautery as a rule works well, but I have 
repeatedly found that if we attempt to increase the strength of the cur- 
rent as the button cools down, the platinum wire gives way and the 
operation suddenly collapses. All the objections, also, which may be 
reasonably brought against the use of the curette are yet more applicable 
to the use of the cautery. Among the chief advocates of this method of 
palliative treatment we must count Fritsch, who trusts to it as the means 
of destroying the infiltrated tissue, and of bringing about similar results 
to those obtained by the efficient use of chloride of zinc. He uses it as 
the special means of producing a result ; not as a supplement to the use 
of the curette, as is strongly recommended by many operators. 

Supposing, in any given case, the endeavour to use Pacquelin's cautery 
for the purpose of destroying the affected tissue in a case of crater-like 
ulcer of the uterus be resolved upon, the parts must be exposed by means 
of a tubular speculum which does not readily convey heat. The tem- 
perature of the cautery has to be kept up with the aid of an efficient 
assistant ; and after the comparatively slight use of the curette the point 
of the cautery button is applied to all the suspected area. There is 
always a certain amount of haemorrhage, and the blood has not only a 
tendency to cool the instrument, but to obscure our view of the field of 
operation. Fritsch trusts entirely to the cautery to produce the desired 
result, and an account of his method of treatment may be worth insert- 
ing here : — 

The patient is placed in the lithotomy position, and the soft portions 
of the uterine ulcer are removed by means of the sharp curette or a large 
sharp spoon. The instrument is firmly and rapidly used to remove the 
whole of the soft infiltrated tissue ; the main reason for prompt and rapid 
action being the important amount of heemorrhage which so frequently 



MALIGNANT DISEASES OF THE UTERUS 707 

occurs. Shreds of uterine tissue which evaded the curette must be seized 
hold of by forceps and cut away. The crater is then thoroughly burned 
out by means of the point of the button of the Pacquelin cautery. If the 
actual cautery be employed, it should be used when it is becoming dull, 
not at the white heat. The burning by means of the cautery should be 
effected in a thoroughly energetic manner, working high up into the 
uterine tissues, and transversely into the parametrium. The process is 
continued until haemorrhage is completely stopped, and until the surface 
of the tissues so treated, when tapped with the cautery point, produces 
an impression as if it were tapping upon horn or cartilage. If the 
speculum show any sign of becoming too hot it must be cooled down 
by means of cold water compresses. Where there has been great loss 
of substance there appears to be some danger of roasting tissues too 
close to the peritoneal surface of the uterus ; it is better, then, to do 
a partial operation and repeat it in two or three days. After the burn- 
ing the cavity is packed with a suitable tampon consisting of dermatol- 
gauze ; the cavity is also treated with an astringent. 

There can be little doubt that it is a good plan, even after such ener- 
getic use of the cautery, to pack the crater with an antiseptic tampon ; 
and this tampon is best applied by means of an exceptionally long 
forceps ; made very much in the pattern of the dissecting instrument. 

After such an operation the completely destroyed tissues begin to be 
shed, either in the form of considerable shreds or of a liquid, the result 
of the breaking down of the tissue internally. 

Fritsch does not think well of the chloride of zinc treatment which 
he has tried in all its modifications for between twenty and thirty years. 
He says it produces a hard cicatrix which becomes denser and harder 
and is ultimately the seat of neuralgic pain ; and all this without stop- 
ping to any great extent the progress of the disease. 

He prefers to apply the curette and remove the soft tissue ; then to 
cauterise, and afterwards to continue to use tampons with a mixture of 
boric and tannic acid. 

Among the agents which have been used in powder, suspension, or 
solution to delay the progress of the disease, to soothe it, and to deo- 
dorise it, may be mentioned alum, thymol, boric acid, salicylic acid, 
carbolic acid, creolin, lysol, and iodoform. There is something to be 
said for each of them ; they are all chemical agents, possessing qualities 
which may be of service in inoperable cancer of the uterus. 

3. Interstitial Injections by the Hypodermic Syringe. — Dissatisfaction 
with the treatment by curette and cautery has led to the attempt to 
treat cancer by the introduction of certain chemical substances into the 
parenchyma of the uterus, just beneath the infiltrated parts. The 
method has been largely of the nature of an experiment, and the results 
published cannot be considered brilliant. 

Thinking that, if the bacterial element in a case of ulcerating cancer 
could be removed, the rate of growth might be diminished and some of 
the disagreeable features in a case might be more or less ameliorated, 



7o8 SYSTEM OF GYNAECOLOGY 

the writer a few years ago tried the injection of small doses of a solution 
of perchloride of mercury into the tissues of the cancerous uterus ; it 
would be too sanguine to describe the results as more than negative, 
except indeed that a good deal of pain was inflicted. The process has 
been tried again at our Cancer Hospital without any better results. 

Within recent years, however, a considerable number of contribu- 
tions to this therapeutic method have appeared in the medical journals, 
and it is claimed by the authors that they have met with encouraging 
success. 

Bernhardt treated six cases with injections of salicylic acid solution 
(6 per cent), and expresses himself satisfied with the results obtained. 

Schultz of Buda-Pesth appears to have begun this treatment amongst 
the first. He gives an account of thirty cases in which he injected 
alcohol ; in his opinion with satisfactory results. The treatment requires , 
much care and time ; it is laborious for the surgeon and painful to the 
patient. 

Yulliet also published an account of his method of injecting absolute 
alcohol. He reported four cases, and was pleased with the result, con- 
sidering one of the cases a brilliant success. He used a large number 
of needles, and he made nine to a dozen " prickings," injecting each time 
three or four drops, if he did not meet with "a too sensitive subject." 
In all the patients the treatment caused considerable pain, and in one 
rather alarming general symptoms. She said she felt as if quicksilver 
were circulating in her blood-vessels. The best result obtained was a 
considerable amount of cicatrisation in the neoplasm, the area of which, 
however, ultimately became neuralgic and gave rise to much pain. 

It is claimed for the process that it causes cicatrisation, diminishes 
discharge, and occasionally produces a perfect cure ; on the other hand, 
it is admitted that each repetition of the injections amounts to a pain- 
ful operation ; that these operations must be frequently repeated, and 
that the result is always uncertain. Vulliet considers the most favour- 
able case the one in which a neuralgic cicatrix remained. 

Suppression of Hmmorrliage and Diminution of the Foul Discharge. — 
As the disease advances these objects become among the chief concerns 
of the medical attendant, apart altogether from operative treatment. 
The one rapidly saps the patient's strength and brings on anaemia ; the 
other poisons her, and makes her an object of distress or disgust to 
herself and to those about her. 

Owing to the irritable condition of the patient's digestive organs and 
lower alimentary canal, it is necessary to make the most of local meas- 
ures. One great difficulty in the treatment is the anorexia; and we 
cannot afford to upset such digestion as there may be by styptic and 
antiseptic remedies — such as mineral acids, tannin, ergotin, or any of 
the turpetine series — administered by the mouth. 

For the arrest of haemorrhage we must trust to pressure by a 
tampon introduced into the vagina, and planted firmly upon the bleed- 
ing ulcer-surface. It is usual to supplement the hsemostatic effects of 



MALIGNANT DISEASES OF THE UTERUS 709 

the pressure by means of a styptic. The great objection to the use of 
the salts of iron for this purpose is the embarrassing discoloration pro- 
duced by them. Each of the other known styptics has had its advocates. 
An endeavour has usually been made to find an agent with deo- 
dorising properties in addition to the haemostatic. The objection to 
terebene and turpentine, combined with oils or in any other way, is 
that they produce a certain amount of pain internally and irritation 
about the external genitals. A weak solution of chloride of zinc, with 
or without the addition of iodoform, makes a useful material for appli- 
cation ; and, among those which I have tried, I know nothing better 
than a solution of acetate of lead in glycerine, with a small proportion 
of carbolic acid and morphia added. 

When the disease is far advanced beyond the stage of active hsemor- 
rhage, it is the foul discharge and the pain which we have chiefly to 
consider in our treatment. The discharge, moreover, frequently, pro- 
duces vulvitis, and dermatitis, inside the thighs and in the groins. We 
must trust largely to internal sedatives to relieve the distress, but the 
smell and irritating character of the discharge may be modified by local 
means — chiefly by the use of the syringe charged with a solution of 
mercury or carbolic acid. An alkaline solution may be occasionally 
advantageous for cleansing and soothing, but the great majority of the 
chemical substances used in solution appear to serve no useful purpose 
whatever. Copious use of warm water, or weak salt and water, is quite 
as useful. The whole object of this phase of the treatment is to ke3p 
the affected parts as little septic as possible, and to prevent discomfort. 

When the stage of the disease is reached at which pain becomes a 
symptom, it is necessary to begin the administration of sedative drugs ; 
and this part of the treatment may be almost entirely summed up in 
the administration of morphia in some convenient form; no other 
drug is to be compared with it in its beneficial effects. Its action may 
have to be supplemented in some cases by sedatives which have more 
of a soporific action, but it may be said with entire confidence that 
there is no substitute for it. In inoperable cases of cancer there can 
be no reasonable ground for hesitating to give whatsoever doses may 
be necessary to afford relief from suffering. In some comparatively 
rare complications, such as pyometra and hsematometra or concurrent 
disease of the Fallopian tubes producing spasm, considerable temporary 
relief may be given by the administration of antipyrin, or the extract 
of viburnum ; but the depressing by-effects of these drugs must be 
kept constantly in mind. In the distress about the anus and vulva, 
from pressure in the comparatively late stages, the action of the morphia 
may be usefully supplemented by the use of an ointment of lanolin 
containing cocaine, morphia, and tannin. When symptoms of renal 
complications come on it is still necessary to continue the use of mor- 
phia, while other measures are taken on the general principle of giving 
relief in kidney disease. It is not as a rule possible, even if it were 
advisable, to put the patient on any regimen dictated by some supposed 



SYSTEM OF GYNECOLOGY 



advantages in the method of diet. The dietary should be as generous 
and varied as possible ; the main difficulty in dealing with the patient 
is not to select the food, but to get her to take any. The object to be 
kept in view is obviously to assist and maintain the nutrition as long as 
possible, and prevent the inroads made upon the strength by haemorrhage, 
septicaemia, and pain. With this object the usually recognised adjuvants 
to digestion, such as pepsine, peptonised foods, and the like, should be 
pressed upon the patient. 

With regard to the effects of the administration of drugs, through- 
out the whole course of the case, for purposes other than the relief of 
pain, our exact knowledge is almost nothing. We know that alcohol 
in suitable doses produces a certain amount of stimulation and a sense of 
well-being, and, if it can be well borne and duly eliminated from the 
system, there does not seem to be any sufficient reason for denying 
some reasonable amount to those to whom it would be a comfort. It 
may be considered, in fact, as an auxiliary to morphia and soporific 
drugs; and, in the latest stages, one of the means of euthanasia. 

Arsenic has so long had a reputation in the treatment of cancer, 
whether internally or by topical application, that we are disposed 
to administer it rather lest we should be depriving the patient of an 
advantage than from any firm faith in its usefulness. If it can be borne, 
the combination of arsenic and iron, either as a pilule of arseniate of 
iron, or as a natural arsenical water, is probably beneficial. I have 
been in the habit of recommending the constant use of arseniate of 
iron to patients after total hysterectomy, and my impression is that a 
certain amount of advantage has been obtained from it. 

Quinine is recommended as a means of diminishing, as far as pos- 
sible, the effects of absorption from the septic area, but it is not well 
borne by the stomach of a cancer patient, and in fact it is only in the 
comparatively early stage that it can be, as a rule, administered with 
advantage. 

The specific treatment by Chian turpentine need only be mentioned 
in passing as one of the numerous empiric methods of treatment which 
excited hopes for a time, among some persons to whom a disease is an 
entity, only to be abandoned like its forerunners in favour. 

As Complication of Pregnancy. — Malignant disease of the cervix as 
a complication of pregnancy and labour is a subject of great scientific 
interest and practical importance. Owing, however, to the comparative 
infrequency of its occurrence, to the great variations in the clinical facts 
of the cases, and to the intermixing of ethical considerations of greater 
or less importance, it is impossible to make a satisfactory classification 
of the cases, or to lay down any rules of universal application. 

When the disease is not far advanced, and it is obvious that the uterus 
could be extirpated without unusual danger or difficulty, the following 
question naturally arises with regard to the interruption of pregnancy : — 
If the pregnancy is not far advanced, are we to wait to the full, 
or nearly to the full term, and permit the cancer to grow rapidly, as it 



MALIGNANT DISEASES OF THE UTERUS 711 

is certain to do in the meantime ? or are we to interrupt labour without 
any consideration for the life of the foetus in utero ? With regard to 
the interruption of pregnancy, which is not effected at the same time as 
the final operation on account of the cancer, we must keep in mind the 
great danger of septic infection during the puerperium owing to the 
manipulations of the malignant new-growth and its continued presence. 
Another consideration, which must influence to some extent the judgment 
of those with Avhom the decision lies, is the prospect of inherited ten- 
dency to malignancy in a child developing in the uterus of a mother 
already the subject of the disease in a more or less advanced stage ; 
even though ordinarily heredity may be almost disregarded as a factor 
in the etiology of cancer. But there is a stronger argument against 
giving too much heed to the child in the adoption of any modern 
method of obstetric treatment. If we compare the results, so far as the 
child's life is concerned, of the earlier practice in cases of cancerous com- 
plications with those obtained since operation has been more largely 
resorted to, we find that in Cohnstein's statistics, published in 1873, 
only 42 children survived in 116, that is, 36-2 per cent. In the 142 
cases quoted by Theilhaber, in giving the statistics for twenty years up 
to 1893, the proportion surviving was 46*4 per cent. 

Now a large number of these survivors of birth die within the first 
few weeks : experience, therefore, shows that in any event the danger to 
the child on the expectant plan of treatment is very great. 

If Ave may infer the opinions from the practice of those who have 
published cases, one would be led to the conclusion that the life of the 
foetus has not been a matter of much concern to most of them, and that 
operations have been undertaken almost entirely in the interests of the 
mother. Even the great exception to this rule appears to show that the 
mother's life and welfare should be our main consideration in deciding 
the time and method of operation. The great exception is the case 
in which the disease has not been discovered until towards full term, 
or when labour has begun. The case has then usually become inoperable 
as a case of cancer ; and the only thing that can be done is to endeavour 
to save the child by the Csesarean section, which also enables the mother 
to live as long as the disease will permit. 

The operable cases of cancer of the pregnant uterus readily divide 
themselves into three largely comprehensive classes. Yet some operable 
and many inoperable cases can hardly be classified; and a study of the 
individual case must guide us to what should be done or left undone. 

The first class includes all the cases in which the cancer is discovered 
before the uterus has become so large as to make removal of it, unopened, 
impossible per vaginam ; that is to say, at the latest in the fourth month. 

To the second class belong those cases in which the pregnancy is too 
far advanced for this comparatively simple proceeding : in these cases 
in order to remove the uterus per vaginam it is necessary first of all to 
empty it by bringing on premature labour while the child is non-viable. 
The third class consists of those cases in which the disease is not dis- 



712 SYSTEM OF GYNECOLOGY 

covered until the woman is in labour and the child is living ; then the 
alternatives are ordinary obstetric management and the Caesarean section 
with complete removal of the uterus. 

Cases of the first class present the most favourable features. The 
malignancy may be developing rapidly, and the amount of haemorrhage 
and offensive discharge may be very considerable; but owing to the 
evolution of the uterus the tissues are remarkably loose, and the process 
of enucleation thus becomes comparatively easy and safe. It is, in 
fact, the most favourable method of treatment if the condition be dis- 
covered in time. Theilhaber gives a list of eleven cases, including 
the cases of Olshausen, Greig-Smith, Brennecke, and Kaltenbach, in 
which total extirpation without opening the uterus was the treatment 
in early pregnancy without a single fatal result. 

When the uterus is too large for vaginal hysterectomy pure and 
simple, it is necessary first to bring on abortion or to perform the 
abdominal operation. But the dangers attaching to Freund's combined 
abdominal and vaginal hysterectomy are too formidable to allow it to be 
entertained except under unusual circumstances. To empty the uterus 
adds appreciable risk to the operative proceedings, inasmuch as there is 
considerable danger of infection. It may be assumed, however, that no 
one likely to undertake the management of such a case would operate 
without every possible precaution; or, if septic metritis occurred in spite 
of such precautions, would allow it to run its fatal course. If, after the 
exercise of every care to prevent septic infection arising from the induction 
of labour complicated with ulcerating cancer, and in spite of all precau- 
tions, suspicious symptoms arise, there should be no hesitation in proceed- 
ing at once to the complete operation of vaginal hysterectomy ; but if no 
untoward symptoms arise the uterus is extirpated at some convenient 
time during the puerperium. Theilhaber gives a list of three cases in 
which this method was adopted, and the result was in each case satis- 
factory. Many other cases, suitable for this method, are mentioned in 
which unsatisfactory and usually feeble treatment was followed ; with 
the results which might have been expected. 

In the third class referred to, when the disease is discovered at or 
about full term, it is usually far advanced ; and, whatever the treatment, 
the results are unsatisfactory. If the os uteri be dilatable the obstetric 
method of waiting until the forceps can be applied appears to give the best 
results for mother and child. In eight cases quoted the mothers all 
survived, and six of the children were born alive. In five cases where 
turning was resorted to three mothers died. 

Csesarean section by any of the methods, or combined with Freund's 
total extirpation operation, gave disappointing results. Eight cases of the 
old method of Csesarean section are quoted ; all the mothers died. After 
Sanger's Csesarean operation, of 13 women only three survived for a 
month or six weeks ; most died directly after the operation. Five out 
of twelve lived after Porro's operation ; and two out of six survived 
Freund's combined method of total extirpation. 



MALIGNANT DISEASES OF THE UTERUS 713 

Cohnstein's statistics up to 1873 show that, including all cases, how- 
ever treated, 72 women died out of 176 — a mortality of 57 per cent. 
Theilhaber's figures for the last twenty years are 162 patients, of whom 
51 died during or immediately after labour — that is, a mortality of 
31*5 per cent. A complete study with recent bibliography will be found 
published by Hernandez in 1894 (32). 

III. Cancer of the Body of the Uterus. — Cancer of the body of the 
uterus is a comparatively rare disease, but published accounts of indi- 
vidual cases do not now indicate it as so rare an occurrence as they form- 
erly did. More exact and earlier observation, and the inclusion of diffuse 
sarcoma and malignant adenoma, as, clinically speaking, cancer of the 
body of the uterus, greatly increase the number of cases. 

The disease under consideration is malignant, and histologically it is 
carcinoma ; but in its clinical features, including its amenability to radi- 
cal and final surgical treatment, it might almost be considered a different 
disease from cancer of the vaginal portion and cervix. This difference is 
all the more striking clinically if we compare primary cancer of the body, 
which is the only disease under consideration at present, with cancer as 
found in the body when it is secondary to cancer of the cervix, Avhether 
by continuous extension or by inoculation during the manipulations of 
treatment, which certainly sometimes occurs. The clinical course of sec- 
ondary cancer of the body is not separable from the course of the primary 
disease from which it sprung; we shall here concern ourselves with 
primary cancer only. 

At the time of writing his monograph, about ten years ago, Gusserow 
had collected from all sources only 122 cases of primary cancer of the 
body of the uterus, including an indefinite number of cases of sarcoma. 
Schroeder diagnosed 28 cases as primary cancer of the body in 812 cases 
of carcinoma of the uterus — that is, 3-4 per cent. 

Krukenberg gave an account of the radical operations for malignant 
disease of the uterus done at the University Clinic for Women in Berlin 
in five years ending with April 1891. O/ 24,887 patients, 924 (3-7 per 
cent) were suffering from malignant disease of the uterus; and of these 
292 (31-6 per cent) underwent surgical operation. The operation in 235 
cases was total extirpation ; and the disease in 197 cases was carcinoma 
of the cervix, in 30 carcinoma of the body, and in 8 sarcoma of the body. 
Here, in a large number of cases diagnosed beyond question, we find 
malignant disease of the body occurring with comparative frequency ; 
the relative frequency to other forms appearing in a much higher pro- 
portion than in older statistics. 

Pathological Anatomy. — Excluding adenoma malignum and diffuse 
sarcoma of the body, genuine carcinoma corporis uteri occurs in two 
fairly well defined forms, according as it originates (ci) in the parenchyma 
or substance of the uterus, or (6) in one or other of the constituent ele- 
ments of the mucosa. The form originating comparatively deep in the 
tissues is described as developing nodules or spheroidal masses in the 



714 SYSTEM OF GYNECOLOGY 

uterine tissue ; these sometimes bulge on the peritoneal surface, sometimes 
on the mucous surface of the uterine cavity; but they have little tendency 
to soften within the uterine wall, or to ulcerate on either peritoneal or 
mucous surface. This form is almost invariably described by writers on 
the malignant diseases of the uterus, but it must be a rare disease ; and 
some cases which have been observed and subjected to careful examina- 
tion have not improbably been either sarcoma or some hybrid form. 

Cancer of the body of the uterus originating in the mucosa varies in 
form according as its seat of origin is the utricular glands or the super- 
ficial epithelium. The most ordinary case of carcinoma of the body 
appears to begin in the utricular glands. These glands at the site of origin 
become blocked by the proliferation of the epithelial elements. This is 
usually described by the pathologist as the ultimate fact in the initiation of 
the phenomena of malignant change in the glands, but the anatomist — for 
example, Symingtonin Quain^ s Anatomy — describes blocking of the deeper 
extremities of these glands as a normal condition. Distension of the 
lumen follows the blocking of the glands, the blood-vessels in the inter- 
glandular spaces become obliterated, and occasionally deposits of pigment 
take place. At a comparatively early stage of this process hardening or 
nodulation, with a certain amount of projection into the lumen of the 
uterine canal, occurs ; and simultaneously there is development towards 
the muscular tissue of the uterus. The condition usually met with on 
examination of the uterus after extirpation is that of an alveolar cancer 
deeply invading the muscular tissue of the uterus; sometimes with 
nodules bulging upon the peritoneal surface, and invariably with a cer- 
tain amount of ulceration towards the uterine cavity. This is the adeno- 
carcinoma described by Pfannenstiel. It is probably thus designated 
because of a distant resemblance to gland tissue which it assumes, but, 
as will be shown later, it is not adenoma malignum in the narrower sense. 
When the cancer begins in the superficial epithelium of the uterine 
mucosa, with invasion of the deeper tissue, there is also a papillary 
formation somewhat analogous to the cauliflower excrescence of the 
vaginal portion of the cervix. It may, however, take the form of mere 
superficial proliferation with necrosis and ulceration, forming a tumour 
comparatively late in its development. This is the adeno-carcinoma 
papillare of Pfannenstiel. Many of the cases described are probably 
epithelioma just as it occurs in the cervix. These, as Fritsch points out, 
are mere forms of the development of the disease in different varieties 
of cancer; and both forms may occur in the same case. 

Quite recently, in some of the German special journals, accounts 
of cases called epithelioma (Hornkrebs) have appeared from time to 
time. I have recently operated upon a case which cannot well be 
described, either clinically or histologically, as other than papillary 
epithelioma of the body of the uterus. Hofmeier describes two 
cases of pavement-epithelium cancerous tumours of the body. In one 
the diagnosis was by the curette and microscope, as total extirpation 
could not be effected; in the other case both a tumour of pavement 



MALIGNANT DISEASES OF THE UTERUS 715 

epitlielial formation and a glandular carcinoma occurred in the same 
uterus. The patient was a virgin of 50 ; menopause at 41 ; haemorrhage 
for \\ years; last half-year purulent discharge in addition. Vagina 
narrow ; portio short ; tumour size of a fist and a half bulging through 
cervix from cavity of body; curette used for diagnosis. Microscopic 
examination led to the belief it was sarcoma. Operation by abdominal 
section and vaginal method combined. Most of the tumour was ultimately 
found to be alveolar cancer, but part of it was unquestionably pure flat- 
celled epithelial carcinoma. 

Several such cases of epithelioma corporis uteri have been reported 
in the course of the current year from various quarters. 

Etiology. — Cancer of the body is comparatively so rare that we have 
no great volume of statistics to apply to and manipulate in the endeavour 
to find some clue to the cause of the disease. One thing is certain, that 
the most striking facts connected with cancer of the body are entirely 
different from the corresponding points in cancer of the cervix. In cancer 
of the body the patients are on the average much older ; they are in a 
different position in life, usually much better cared for from laeginning 
to end than the class of women most frequently affected with cervical 
epithelioma ; and whereas the subjects of cervical epithelioma are, with 
few exceptions, parous, most of them multiparous, many of them remark- 
ably prolific, the subject of corporeal cancer is almost invariably either 
elderly maiden or barren wife. All my five cases were Avomen past the 
menopause : two were married, but only one had been pregnant ; the 
rest were unmarried. In the case of the parous patient a hard, localised 
papillary carcinoma projected from the fundus, and this fact suggests that 
there is something different in the etiology of such rare tumours from those 
usually met with in the body of the uterus in elderly women. Kelevant 
to this supposition is, for example, the apparent exception of Chiari's 
three cases quoted by Gusserow. The patients were married, child- 
bearing women, in whom the malignant disease made its appearance 
soon after child-bed. But these cases have since been shown to have 
been not carcinoma, but deciduoma malignum. 

Tlie symptoms of cancer of the body of the uterus in its early stages 
are as constant as the symptoms in the corresponding stage of epithelioma 
of the cervix. The most constant is haemorrhage which, in the post- 
climacteric cases, is characteristic. In cases in which the disease occurs 
before the menopause, the haemorrhage at first bears some resemblance to 
that which is caused by fibromyoma of the uterus. It is often menorrha- 
gia, a profuse and prolonged menstruation, not an ordinary metrorrhagia. 
Too much, perhaps, has been made of this symptom in the ante-climacteric 
cases, as the number of cases reported is comparatively small, and gener- 
alisation a rather rash proceeding : in differential diagnosis too little 
has been made of the fact, that fibroids producing haemorrhage in the 
immediately ante-climacteric period of life are usually well known to exist, 
and the cause of the haemorrhage is consequently known. Besides, such 
fibroids are almost invariably sufficiently large to settle, without further 



716 SYSTEM OF GYNECOLOGY 

consideration, the question of cancer of the body of the uterus. In the 
great majority of cases the haemorrhage has recurred after the complete 
menopause. It is, as a rale, comparatively slight, and at first there is no 
other symptom at all; there may be lumbar or hypogastric aching from 
the congested condition of the uterus, and from the reopening of the 
senile internal os uteri. The haemorrhage is slight and continuous, and 
there may or may not be some leucorrhoeal discharge between the periods 
of bleeding. The haemorrhage often continues for a long time before the 
patient seeks for medical treatment. In one typical case of alveolar 
cancer, occurring in a maiden lady of fifty, whom I had under treatment 
for a considerable time, finally extirpating per vaginam, the menopause 
had occurred two years before the symptomatic haemorrhage began; 
and the haemorrhage had gone on for twelve months before the 
patient mentioned the fact to anybody. By this time pain had 
also become troublesome, and in this relation of the symptoms of 
haemorrhage and comparatively early pain we have one of the most 
marked differences in cancer of the body from cancer of the cervix. 
When the cancer assumes a form of superficial epithelial change, pro- 
ducing a localised comparatively hard mass acting like a foreign body 
as in the case to which I have just referred, pain comes comparatively 
early, and ultimately is acute, it may be agonising : it is also frequently 
paroxysmal, and this fact, taken with the existence of great hypertrophy 
of the muscular tissue of the uterus, suggests that pain is caused by an 
effort of the uterus to shed or expel the diseased endometrium like a 
foreign body. 

Another fact in support of this view of the cause of the pain, 
is that in such cases the os uteri is thinned out as in the case of sub- 
mucous fibromyoma approaching the state of polypus ; and the cervical 
canal is comparatively wide. 

In cases of another class pain may be trifling or almost absent to 
a comparatively late stage of the development of the disease. This 
fact was well illustrated in two cases in which I removed the uterus 
during the last twelve months. One was a typical case of adenoma 
malignum, in which, after repeated curettings, the disease had destroyed 
the endometrium, and at the time of extirpation had left little but a 
tolerably thick layer of muscular tissue. In the other case, from a site 
of origin probably in the utricular glands, comparatively rapid ulcera- 
tion had advanced, until little of the original structure of the uterus 
was left except a thin layer of muscular tissue and the comparatively 
soft peritoneal covering. There was no hardness or nodulation in either 
case ; and the steady uniform necrosis, with free exit for the liquefied 
tissue, appeared to have some causal relation to the immunity from pain. 

Even in the later stages of malignant disease of the body of the 
uterus, there is no pain analogous to that which arises, in cancer of the 
vaginal portion and cervix, from infiltration of the parametrium and 
interference with the neighbouring organs, especially with the urinary 
organs. The pain in the later stages is not from pressure, but from 



MALIGNANT DISEASES OF THE UTERUS 717 

peritonitis. In the first case to which reference has been made the peri- 
tonitic pain was extremely well marked after paroxysmal pain had dis- 
appeared under treatment ; and on extirpation it was found that a 
considerable quantity of fluid, which was turbid and contained shreds 
of lymph, had collected in Douglas' space ; and bosses of cancerous mate- 
rial were found bulging in various positions upon the peritoneal surface. 

Another point with regard to the pain of cancer of the body, when 
it does occur, is that after the first haemorrhage there is no symptom 
analogous to the distress from tension produced by pyometra, which, 
by closure of the internal os, is so often a complication of epithelioma 
of the cervix uteri. " The intense agonising pain at an early stage of 
the disease," of which Gusserow speaks, appears to be symptomatic 
only of circumscribed adeno-carcinoma of the loody. 

Another constant symptom of cancer of the body of the uterus is a 
discharge — not hsemorrhagic or sanguineous. As compared with cancer 
of the cervix, however, this symptom comes on comparatively late, and 
the discharge is different. It is different in being thinner and less turbid ; 
and, although foetid, it is usually much less offensive. The absence of 
the intensely offensive odour of cancer of the cervix is probably due to the 
absence of infection by bacteria. It is, perhaps, also on account of the 
comparatively late occurrence of infection of the ulcerating surface that 
saprsemic symptoms, with emaciation and cachexia, are comparatively 
late in appearing in a case of cancer of the body. In all the cases which 
I have seen, the least developed of which was twelve months from the 
beginning of the haemorrhage, the aspect was that of anaemia, not of 
cachexia; and in the last case of all, although the haemorrhage had con- 
tinued at intervals for over a year, there was no appreciable loss of flesh. 
Emaciation comes after the anaemia, after the slight feverishness of the 
sapraemia ; and the loss of rest ensues on the beginning of pain, the use 
of drugs, and the unexplained influence upon the digestive organs of 
malignant disease anywhere in the body. 

The other symptoms and complications arising from cancer of the 
body are late in appearing. Metastases do not readily occur ; and even 
infection of the lymphatics, after repeated curettings and interferences 
with the uterus, is strangely slow in appearing. With the invasion of 
the lymphatics in uterine cancer comes the reaction of the connective 
tissue invasion which produces fixation of the uterus; and in the absence 
of lymphatic infection in cancer of the body is probably to be found the 
explanation of the fact, that in cancer of the body the uterus is seldom if 
ever found to be fixed until a very advanced stage of the disease is reached. 

My first case of extirpation of the uterus well illustrates the extent 
to which local and general changes may occur, and the length of time 
which may be occupied by these changes without lymphatic invasion or 
metastases ; so that the capacity for full recovery still remains. After 
repeated curettings, the administration of drugs, and frequent haemor- 
rhage and foul discharge during an unnecessary delay of twelve months, 
which was owing to the decided diagnosis of sloughing fibroid made by 



7i8 SYSTEM OF GYNECOLOGY 

a well-known gynaecologist, my patient had reached a point of emaciation 
and suffering from agonising pain in the uterus, and disgust produced by 
the foul discharge, which no general or local medication seemed to re- 
lieve : thus the only alternatives became euthanasia or total extirpation. 
The operation was performed eight years ago, dating to the time of writ- 
ing, and within a week an entire change had come over the patient. She 
was free from pain, had escaped all the misery of pervading malodour, 
and had begun to take food. Since the time of complete convales- 
cence from her operation she has, I have reason to believe, required 
no medical treatment of any kind; and she is perfectly well at the 
present time. 

Considering the amount of uterine peritonitis in this case, and the 
softness of the bosses on the peritoneal surface of the uterus, it is 
pretty certain that if the patient had been left untreated a short time 
longer death would have occurred from peritonitis, as has sometimes 
been the case, though wonderfully rarely. 

Diagnosis. — In a case of cancer of the body, after the completion of 
the menopause, there should be comparatively little difficulty in establish- 
ing a diagnosis. It may be difficult or impossible to say what form of 
malignant disease exists ; but the diagnosis of malignancy should not be 
difficult, and this is sufficient for all practical purposes. The particular 
form of malignant disease is seldom diagnosable from the symptoms and 
from the examination of shreds of endometrium ; and, when the extirpated 
uterus is in the hands of the pathologist, it is sometimes even still a mat- 
ter of doubt. When malignant disease of the body occurs before the meno- 
pause, there are only two other conditions or combinations of these which 
can produce symptoms likely to lead a well-informed practitioner into 
difficulty : these are necrosing fibroid polypus or subserous fibromyoma- 
tous tumour, and incouiplete early abortion with slight bacterial infection. 

In the case of cancer of the body, the cervix on digital examination 
gives, as a rule, the impression of being unchanged. The lips may be 
thinned out in cases of the class already referred to ; but as a rule no 
such change has taken place. It is stated also, by some authors, that the 
exposure of the vaginal portion by the speculum does not assist the diag- 
nosis. In the cases which have come under my observation there has always 
been a change in the endometrium, even of the vaginal portion. There is 
a suggestion of activity and hypersemia, an indescribable change of colour 
of an unwholesome kind. It is a hypersemia confined to the mucous lining 
without any other obvious change ; and this change of colour and consist- 
ency is seen in an extremely marked form even after total extirpation of 
the uterus. On physical examination, per vaginam and bimanually, the 
uterus may not be found greatly changed in size or shape. In old 
virgins the examination should be invariably made with the aid of an 
anaesthetic ; and then it will be almost certainly found that the changes 
ascertainable by palpation are sufficiently marked to arrest attention. 
Some slight departure from the normal symmetry of the organ, a, greater 
or less departure from homogeneity in the resistance to pressure, hardness, 



MALIGNANT DISEASES OF THE UTERUS 719 

softness, or elasticity, are signs which, must receive attention, and to 
which due weight must be attached in the diagnosis. 

When the diagnosis of marked disease brings up the question of such 
a serious operation as total extirpation, there is much to be said for 
complete exploration by dilatation so as to permit the entrance of the 
index finger into the cavity ; but this proceeding, not without danger 
in the senile, is apt to produce metritis or endometritis or peritonitis 
which may greatly embarrass the operation and make it more dangerous. 
Such manipulations are also undesirable on account of the ever present 
risk of producing sudden activity of the malignant process, which, after 
the production of a wound, might possibly result in lymphatic infection 
or in some other local infection by contact. 

Kapid dilatation, it may be with the aid of an anaesthetic, and the use 
of the sharp curette or spoon, should make a final and definite diagnosis 
possible at once. There is nothing else in nature like the shreds thus 
obtained in a genuine case of malignant disease. It may be objected 
that the broken-down tissue of a sloughing fibroid is extremely like the 
tissue of a spindle-celled sarcoma. This is one of the cases in which 
assistance in diagnosis may be obtained by comparatively slight and easy 
microscopic examination. If any doubt can possibly exist, the differences 
revealed by the microscope are so obvious that any further difficulty be- 
comes hardly conceivable ; especially as there is always the history of the 
case to guide the judgment. With a definite history, such as may be 
obtained in cases of post-climacteric activity in the uterus, neither dilata^ 
tion nor curetting may be necessary to a diagnosis justifying operation. 
The use of the uterine sound or, better still, of a long surgical probe, 
gives the impression of either roughness and irregularity, or of irregu- 
larity and friability in the body of the uterus that has no parallel in 
uterine disease. The probe, even when used in the gentlest fashion, is 
perceived to sink into the friable tissue, and such trifling manipulation 
is followed by an altogether disproportionate amount of haemorrhage. 

The differential diagnosis of ante-climacteric cases from fibroid 
tumour, or retained portions of early blighted ovum, ma}^ be worth con- 
sideration ; although, a short period of observation being granted for the 
purpose of diagnosis, any important difficulty is hardly conceivable. In 
the case of blighted ovum there must be something in the circumstances 
imphdng the possibility of pregnancy, and a history of symptoms sug- 
gesting occurrence of pregnancy. Even with an offensive discharge, the 
appearance of the uterus when exposed by the speculum and volsella is 
altogether different from that which contains a malignant tumour; the 
physiological as contrasted with the pathological colour of the mucosa is 
unmistakable ; and, finally, dilatation permitting the use of the curette 
must at once dissipate any doubt as to the nature of the condition : a 
tumour, however friable, is attached ; a retained portion of ovum is free 
to come away on slight handling. 

In the case of sloughing fibroid in a woman before the menopause, the 
circumstances may be such as to make the diagnosis doubtful until part 



720 SYSTEM OF GYNAECOLOGY 

of the tissue is examined ; but this must be a very rare occurrence. The 
hsemorrhage in the case of the fibroid is profuse menorrhagia ; the inter- 
menstrual discharge, if the patient have undergone no treatment, is 
hydrorrhoea, not a malodorous, turbid, sanious, or dirty water discharge. 
However anaemic the patient may be from the loss by haemorrhage and 
discharge, the cervix, as revealed by the speculum, will give the im- 
pression of health. 

In the case of the fibroid subserous tumour or polypus, the cervix will 
be comparatively soft, and the cervical canal more or less dilated. If any 
doubt continue to exist, dilatation to permit of digital examination may 
have to be effected, and some portion of the tissue removed. The only 
possible smooth, circumscribed tumour which can simulate fibromyoma is 
sarcoma ; and an easy, rapid, microscopical examination of even a particle 
of the debris of tissue should finally settle the question. But no such 
question need arise. The naked-eye appearances of the two tumours are 
distinct : the sloughing fibroid, even when blackened in colour, is not so 
easily torn ; and when torn it still shows the fibrous structure in the 
shreds : the malignant tumour, like all malignant tissue in the uterus, 
if not soft, is always friable, and is thus easy to distinguish from any 
possible form of fibromyoma in any condition which it ever assumes. 

Tlie prognosis in cancer of the body of the uterus is much more 
favourable than in malignant disease of any other portion of that organ. 
It is long after the initial stages of the disease that lymphatic infection 
occurs ; and consequently fixation or even embarrassment of the move- 
ments of the uterus is an incident of an advanced stage only. This long 
, continuance of mobility greatly favours surgical treatment ; and, as a 
matter of experience, comparatively few cases of this affection come into 
the hands of the gynaecologists in an inoperable condition. Krukenberg 
found 63-2 per cent of cases of cancer of the body still suitable for 
operation. The risk of operation is said by some to be greater, for 
example by Mangiagalli on a very limited experience ; but the prospects 
of the patient who has recovered are immeasurably more hopeful than 
after recovery from the same operation for cancer of the vaginal portion. 

An important source of danger in the course of the operation — one 
which, perhaps, may not be sufficiently guarded against — is that of in- 
fection of the vaginal or of the peritoneal wound. In many of the cases 
of recurrence after cancer of the body the disease could be distinctly 
traced to contact infection. 

Krukenberg's report in the paper already referred to shows the f avour- 
ableprospectsafterextirpationforcancerof the bodyin a very striking way. 

Of 26 patients there were free from recurrence after one year 18 
(69-2 per cent) ; of 16, after two years, 13 (81*2 per cent) ; of 13, after 
three years, 9 (69-2 per cent); of 11, after four years, 7 (63-6 per cent) ; 
of 5, after five years, 4 (66-7 per cent). The results would probably 
have appeared better still if information concerning the missing patients 
had been obtained. 

Hofmeier mentions one case of Schroeder's in which no relapse had 



MALIGNANT DISEASES OF THE UTERUS 721 

occurred after fifteen years. He gives also the history and results of 23 
cases of operation of his own. In 4 it was necessary to perform the 
abdominal operation on account of the size of the uterus or of complica- 
tions ; and the patients all died in from two to eight days. Of the 19 
operated on per vaginam only one died from the operation, and Hofmeier 
states that this was the only death in his last 60 cases of vaginal 
extirpation. In two of the surviving cases, in which the disease was of 
long standing at the time of operation, a recurrence took place in the 
first year, and one died suddenly from some unknown cause ; all the rest 
were well at the time of the report, thus implying from one to eight years 
of immunity from the disease after operation. 

Treatment. — When cancer of the body of the uterus is diagnosed 
before fixation has occurred, or before complications and lymphatic in- 
fection have made operation useless, there is only one method of treat- 
ment to be considered ; that is, total extirpation per vaginam. 

The experience of every year gives greater confidence to the advocates of 
this method of treatment. The technique of the operation continues to im- 
prove, and all experienced operators bear testimony to the smallness of the 
immediate risk to life and the excellent prospects of perpetual immunity. 

Much harm is frequently done by temporising and meddling in an 
ineffectual way. There is in too many cases a history of medical treat- 
ment without examination ; but it must be admitted that it requires 
faith and consciousness of knowledge to insist upon an early physical 
examination in the case of an elderly maiden lady. 

Again we learn that the curette has been used, and something applied, 
and that the symptoms to some extent improved ; this merely implies 
in all probability that the haemorrhage temporarily disappeared, and 
thus still further time was lost. 

In cases of this class my impression is that the practitioner is too 
shy of hinting at cancer, which idea after all has probably taken posses- 
sion of the patient's own mind already. 

After the least possible amount of manipulation consistent with form-, 
ing a confident diagnosis, the operation of total extirpation should be 
performed without delay. 

With regard to the operation there is little to be said that does not 
apply to the same operation for any other condition. One danger to be. 
avoided is to prevent contact infection and consequent early recurrence 
from extravasation of the cancerous fluid. In portio cancer you may use 
the curette or scissors as the first step in the operation ; the analogous 
step in corporeal cancer is to suture the external os so as to prevent any 
fluid from escaping. 

A difliculty frequently arises from the senile condition of the vagina 
and parts generally. So difficult is the operation sometimes made by the 
narrowness of the vagina in an elderly maiden that it is possible to com- 
plete it only by making a free deep incision through the perineum. 
Retractors which, without considerably lacerating the parts, will stretch 
them to the uttermost, are also essential. 

3a 



722 SYSTEM OF GYNMCOLOGY 

On account of this difficulty many operators have recommended the 
sacral operation, and probably still more the combined vaginal and 
abdominal method. We have seen, however, how terribly fatal Freund's 
operation is in even the best hands, and the drawbacks of the sacral 
method are too serious to justify it save under very exceptional cir- 
cumstances. I do not regard the difficulty of a narrow vagina and senile 
change as so great as it has been sometimes represented. No opera- 
tion of the kind could hardly appear more formidable than one which I 
performed recently on a virgin of over 60 years ; but my first step was 
to make a free incision in the middle line of the vagina from an inch 
below the uterus right down and through the perineum to the sphincter. 
The last step was to stitch up this wound, and it healed perfectly with- 
out reaction or flaw. 

In a far advanced case, when radical operation is out of the question, 
the methods of giving relief are exactly those employed in inoperable 
cancer of the vaginal portion and cervix. The prospect of keeping the 
patient fairly comfortable is moderately good. Haemorrhage can be kept 
within bounds by means of the curette and tampon. The danger here is 
rather uraemia than septicaemia : it is the blood-poisoning and accom- 
panying fever which saps the strength. Hence the need for every effort 
to keep the area affected as nearly aseptic as can be managed. 

The complications of the later stages of cancer of the body differ 
considerably in an anatomical sense from those produced by disease 
beginning in the cervix ; but the symptoms are practically identical, 
and the methods of giving relief from sufferings are the same. 

IV. Sarcoma. — Sarcoma is a comparatively rare form of malignant 
disease of the uterus. Still it occurs sufficiently often to make it a 
matter of importance to the practical gynaecologist ; it is not a mere 
matter of scientific interest to the pathologist. Sarcoma may occur at 
any period of the sexual life of the woman over 20 years of age ; but 
like carcinoma it is found comparatively often in the years just before 
or just after the menopause. It may be accidentally met with during 
the climacteric period also. 

Three (34) well-defined forms of sarcoma of the corpus uteri only 
will be described and treated of here. The first is the form, occurring in 
tumours or masses, which is so often mistaken for fibromyoma of the 
uterus ; the second is the diffuse form found, in its earlier stages, in or 
near the endometrium, and bearing a strong resemblance in its clinical 
aspect to carcinoma of the body of the uterus. The third is sarcoma 
botryoides, which calls for little notice. 

The development of the first variety has a striking resemblance to 
the growth of fibromyoma ; and, in fact, all the details in the study of 
it are closely analogous to those of fibromyoma. 

A woman who is approaching the climacteric period of life knows or 
suspects she has a tumour of the womb. She is led to look forward to 
abatement of her symptoms and diminution or disappearance of the 



MALIGNANT DISEASES OF THE UTERUS 723 

tumour with the cessation of menstruation. Instead, however, of her 
hopes and expectations being fulfilled the tumour, which may have been 
almost or altogether stationary, begins to grow, the haemorrhage increases 
and becomes irregular, or it is replaced in time by a thin, watery, sanious 
discharge. The iibromatous tumour, which has been painless, begins to 
cause uneasiness, and ultimately gives rise to intolerable pain. The 
patient takes on an aspect of suffering and deterioration of health not 
sufficiently accounted for by the anaemia owing to the discharge ; she 
gradually loses flesh and assumes a cachectic appearance. When ex- 
amined after some weeks or months of medical routine treatment the 
uterus is found to be iixed, and the floor of the pelvis has the stony 
hardness of the middle stage of perimetritis. The infiltration of the 
tissues of the broad ligament affects the ureters and kidneys in the same 
way as in the corresponding stage of cancer of the cervix, and the ter- 
mination may be the same ; or symptoms owing to metastases in dis- 
tant organs may arise, and the fatal termination come rapidly. 

These are the chief facts in the history of a case of fibrosarcoma 
uteri, the form of the disease which is due to the transformation of fibro- 
myoma into sarcoma. It is, I believe, by far the most common of 
the forms of sarcoma of the uterus, although some regard the diffuse 
form as the most frequent. 

The second form of sarcoma of the body, as usually described, closely 
resembles the diffuse form of carcinoma of the uterine mucosa ; and it 
is only to be clearly distinguished from carcinoma by the microscope. 
And in some cases there has even been a difference of opinion among 
(competent clinicians and histologists as to the exact nature of the 
neoplasm, with the clinical symptoms and the microscopic appearances 
of removed tissues in evidence. In some of these cases there has prob- 
ably been some intermediate condition between carcinoma and sarcoma. 

A variety of this form is cystic sarcoma, of which a considerable 
number of cases have been described by competent observers. This is, 
pathologically, merely a cystic conformation of the interstitial variety, or 
myoma sarcomatodes ; but it has sufficiently special clinical features 
almost to require a separate classification and description for the efficient 
exposition of its characters, their origin, and their practical consequences. 

Many cases of sarcoma of the body of the uterus have been described 
as exhibiting such individual peculiarities that it would not be possible to 
reduce them to any classification which could serve a useful purpose. We 
must rest satisfied with describing all that pertains to the individual case. 

The same remark applies to sarcoma of the cervix. It is a com- 
paratively rare disease, and the anatomical situation is the only thing 
sufficiently in common to serve as the nexus for any clinical account of 
the individual cases. The most striking form occurring in the cervix is 
the sarcoma botryoides or grape-cluster tumour met with not only in 
children, but at any later period of life. 

Pathological Anatomy. — A. The interstitial form of sarcoma is 
analogous in structure to the fibromyoma of the uterus as it is fre- 



724 SYSTEM OF GYNECOLOGY 

quently, perhaps always, a transformation of the common benign tumour. 
Some of the cases described, even when definite tumour masses existed, ap- 
pear to have been soft sarcoma derived from the endometrium. As a rule, 
the new growth consists of one or more circumscribed masses, not to be 
distinguished by form or consistency from myoma. They are probably 
the " oedematous tumours " which gynaecological surgeons remark on as 
uninfluenced in their growth by castration. Histologically they show a 
proliferation of round cells, more or less replacing the normal tissues of 
the uterine wall. From Virchow and Schroeder to the present time the 
vast weight of authority has been in favour of the view that interstitial 
sarcoma is a malignant transformation or degeneration of the ordinary 
fibroniyoma; and many sarcomatous tumours have been described which 
exhibited marked traces of their origin. It would be superfluous to 
quote authorities or describe even typical cases to substantiate and 
illustrate that which all recognise and accept. 

Von Kahlden, in an important contribution on sarcoma, while sup- 
porting the usually accepted opinion of the origin of the disease, mentions 
a case in which the seat of origin of the tumour was in the blood-vessels, 
the result being a well-marked angio-sarcoma. 

An attempt has been recently made to prove from the histological 
examination of operation material that sarcomatous tumours may arise 
from the muscular tissue elements of the uterus. Dr. Whitridge Williams 
has published a paper, highly valuable in many other respects, in 
which he describes a case under the designation of sarcoma-like myoma 
of the uterus (myoma sarcomatodes uteri). The patient was a nulli- 
parous woman of 47, who had passed the menopause four years. A few 
weeks before admission to the hospital she began to show marked 
emaciation and oedema of the abdominal walls and lower extremities. 
The abdomen was filled with "large tumour masses which were 
diagnosed as malignant growths arising from the generative tract." 
The patient died without surgical treatment. A detailed description 
is given of the macroscopic appearance of the tumour, and of the results 
of histological investigation. Williams came to the conclusion that the 
new growth was derived from a proliferation of the muscle cells, and not 
from the connective tissue. After quoting some questionable authority, 
he proceeds to say, " It is evident that fibromyomata may be transformed 
into sarcomata either by the proliferation of the connective tissue cells 
between the muscle bundles, or by the proliferation of the muscle cells 
themselves." 

Unfortunately this statement promises to lead to discoveries too 
frequently made in gynaecological pathology. Such observations do 
not long remain isolated. Diihrssen, for example, describes a case of 
submucous fibrosarcoma in which he extirpated the uterus. The tumour 
presented a marrow-like appearance, and where it bulged out in the 
uterine cavity it was studded with knobs which on section simulated 
brain substance. It could be shelled out of its bed, and was enclosed in a 
capsule of which, by careful manipulation, considerable portions could be 



MALIGNANT DISEASES OF THE UTERUS 



725 



peeled off. The principal mass of the tumour proved to be a round-celled 
sarcoma in which traces of smooth muscular tissue could still be made 
out. The presence of a capsule and the remains of muscular tissue re- 
moved all doubt. The tumour was originally a simple myoma which 
had undergone malignant degeneration four years after the menopause. 
This tumour formed the material for the observations embodied in a 
laborious work by Pick, in which he endeavoured, among other things, 
to prove the muscular origin of sarcoma of the corpus uteri. 

Pure spindle-celled sarcomas also occur. These when they soften 
and disintegrate, shedding their debris through the uterine canal, give 
rise to symptoms which closely simulate those of sloughing fibromyoma. 

The analogy to fibromyoma still holds, even with regard to pedun- 
culated tumours. These also have been found undergoing sarcomatous 
transformation. 

Whether such tumours may have also a capsule like a circumscribed 
fibroma used to be a disputed question. So many cases have, however, 
been observed by competent clinicians and pathologists in the transition 
stages, that it may be stated as a fact beyond further discussion, that 
even malignant tumours of the body of the uterus may have a distinct 
capsule, and may to this extent correspond still further in structure with 
the benign tumours. 

B. Diffuse sarcoma of the corporeal mucosa resembles, as has been 
said, the typical form of carcinoma of the same structure. "The term 
diffuse sarcoma, sarcoma of the uterine mucous membrane, has been used 
since Virchow's time to designate a new growth, proceeding from the 
connective tissue of the uterine mucous membrane, consisting mostly of 
small, closely-packed, round cells, though sometimes of spindle-cells, and 
constituting an exceedingly soft, friable infiltration of the mucous mem- 
brane" (15). 

C. The third definite form of sarcoma of the uterus, sarcoma botry- 
oides, or grape-like sarcoma, affects the cervix and occurs in the years 
just after puberty or after the menopause. A few cases which may be 
included in this class have been described as sarcoma of the corpus uteri. 
The first case appears to have been reported by Spiegelberg in 1872. 
A considerable number of cases were described, and the pathology was 
discussed during the next twenty years, and various names were sug- 
gested, until Pfannenstiel published his monograph in 1892, and pro- 
posed the term "das traubige Sarcom," or grape-like sarcoma. He 
opposed the view that the disease was a myxoma, and accepted Weigert's 
explanation of the histological appearances, which indeed in its essential 
points may be considered as established. The cyst-like masses, re- 
sembling hydatid mole, consisted chiefly of large round and spindle cells 
with clear spaces separating them. These spaces were traversed by a net- 
work of fine thread-like tissue and blood-vessels, and were filled with 
lymph corpuscles. The new growth was oedematous, not myxomatous ; 
and its attenuated enclosing structure consisted of squamous epithelium, 
which was covered by a layer of cylindrical cells with indistinct cilia. 



726 SYSTEM OF GYNECOLOGY 

The cavities containing lymphatic fluid were not lined with epithelium, 
and therefore not glandular. The growth in Pfannenstiel's case took 
its origin from the superficial parts of the mucosa of the cervix, and 
derived its peculiar conformation from the papillary structures at its site 
of origin. The ultimate fact in its origin appeared to be some change 
producing proliferation in the lymphatics and blood-vessels. 

Perhaps the most important of recent contributions to this subject is 
that of Pick, whose conclusions may be shortly stated. 

Sarcoma botryoides, as observed in the cervix uteri of adult women 
and children, and the vagina of children, is in every respect a special 
variety of tumour characterised by its grape-like form. Clinically it is 
extremely malignant. Anatomically it develops from the most super- 
ficial layer of the mucous membrane ; it spreads first in the superficial 
portions of the mucosa ; it shows a strong tendency to invade the deeper 
tissues ; and it assumes the grape-like form owing to the freedom with 
Avhich it may expand and become oedematous in the wide cavity of the 
vagina. 

The extreme rapidity of development of this form of sarcoma is 
accounted for by its greater virulence and the rapid circulation of the 
lymphatic stream in the subepithelial layers. The grape-like conforma- 
tion is explained by the original papillary development, the freedom for 
expansion, and the dropsical condition brought about by interference 
with the blood and lymphatic circulation at the neck of each individual 
papillary element. 

Symptoms and Course. — As compared with carcinoma, it may be said 
that all the forms of sarcoma run a more rapid course than the corre- 
sponding carcinomata, after the symptoms first attract attention. 

It would be useless to attempt to separate the various forms in 
any general description of the symptoms produced; indeed it is not 
possible to establish exact diagnostic symptoms marking them off from 
carcinomata, for whatever suspicions may be aroused and surmises made, 
the differential diagnosis is only established by means of the microscope, 
after operation or death. 

The fibrosarcoma gives rise at first to the same symptoms as the 
fibromyoma. It is only when a tumour begins to grow rapidly at the 
time it ought to diminish that the suspicion of malignancy is excited. 
It may be laid down as a rule, with few if any exceptions, that an 
apparent fibromyoma, which begins to grow at the menopause, is under- 
going sarcomatous transformation. The apparent exception, a case of 
activity, not of enlargement, in a post-climacteric uterus which is the 
seat of tumour, is the separation of a submucous fibromyoma which has 
undergone a certain amount of shrinking, and has become starved by 
interference with its nutrition due to senile changes. 

When post-climacteric growth of the tumour occurs two symptoms 
soon appear. One is pain owing to tension resulting from the rapid 
growth, and often from invasion of the circumuterine connective tissue ; 
the other is marked deterioration in the general health. Quite recently 



MALIGNANT DISEASES OF THE UTERUS 727 

I performed abdominal hysterectomy on a patient suffering extremely 
from pressure symptoms, owing to jamming of a large uterine tumour in 
the pelvis. The case had been erroneously diagnosed as sarcoma, although 
the patient had not reached the menopause. I operated for fibromyoma, 
although it would be difficult to state explicitly the grounds for con- 
fidence in that diagnosis, apart from the aspect and the absence of marked 
deterioration of health. We may observe distinct anaemia from bleeding 
fibroid, but there is more than aneemia in the case of fibromyoma sarco- 
matosum : there is an aspect, accompanied by marked loss of strength, 
which the patient takes on early ; the expression of suffering comes later. 
A few years ago I was consulted in the case of an unmarried woman of the 
post-climacteric age who, until a week or two before, had been under- 
going the electric treatment for fibroid tumour. The pelvis was filled 
by a hard, irregular mass, and the uterus was absolutely immovable. 
The history of tumour had existed for years. There was profuse 
hsemorrhage and much pain, but no offensive discharge. Erom the ap- 
pearance of deterioration of health, including loss of flesh, the diagnosis 
of rapidly growing sarcoma was given, and, after the patient's death, 
Avhich occurred a few weeks later, this opinion was proved to be correct. 

If the neoplasm is developing from a submucous fibromyoma or 
polypus, there will be severe haemorrhage and pain from the efforts of 
the uterus to expel the tumour. If such a tumour be removed there is 
soon recurrence ; but the expulsion of several polypi at intervals, although 
suspicious, is not to be considered diagnostic of malignancy. " Recurrent 
fibroid," and therefore malignant it may be ; but it may be, and in the 
preclimacteric case more probably is, merety expulsion of several pre- 
viously existing submucous fibroids which have shrunk on account of 
senile changes. 

As the sarcomatous neoplasm advances in growth, in addition to 
occasional violent haemorrhage, it may cause a sanious hydrorrhoea ; 
even though it is not necrosed. This discharge sooner or later takes on 
an offensive odour. The tumour, moreover, may become gangrenous, 
and give rise to septicaemia more or less acute, according as surgical 
treatment has been attempted or not. 

Owing to the intense anaemia, sapraemia, and marasmus, death is 
readily produced by peritonitis or obstruction of the intestines ; or from 
pressure on the ureters. It is often preceded by oedema of the abdomi- 
nal walls and legs, partly from pressure, partly from failure of the heart. 

In the diffuse mucous form of sarcoma the symptoms are not dis- 
tinguishable from carcinoma affecting the same structures. There is 
usually a profuse leucorrhoea occasionally mixed with blood ; and severe 
haemorrhage may occur, but not as a rule. It is rather persistent and 
irregular. 

Pain as a symptom is variable. It is as a rule more severe than in 
the corresponding stage of any other form of malignant disease of the 
body, but cases have been mentioned in which it was entirely absent. 
The pain probably depends upon several causes. It may be, as suggested 



728 SYSTEM OF GYNECOLOGY 

by Gusserow, that it depends upon the depth to which the sarcomatous 
infiltration has penetrated, and that the immediate cause is " some mor- 
bid change in the terminal nerve filaments." From the frequency with 
which the os internum is partially or wholly blocked from within by the 
infiltration resulting occasionally in hydrometra or pyometra, the pain 
must be sometimes owing to efforts of the uterus to expel its contents. 
It is then partly a uterine colic. 

Later in the course of the disease the peritoneum may become 
invaded, or the disease may penetrate the walls of some of the neigh- 
bouring organs. 

Metastases are rarer than in the fibrosarcomata, but the diffuse 
mucous form extends continuously at a greater rate. 

Diagnosis. — With the exception of the rare sarcoma botryoides of 
the cervix, sarcoma cannot be positively diagnosed without microscopic 
examination. 

The first thing to be done is to observe the clinical symptoms care- 
fully, and endeavour to settle the question of malignancy. If the malig- 
nant character of the tissue-changes in the uterus be once definitely 
established and acted upon, there will be time to distinguish by suit- 
able means the particular kind of tumour from all others which it 
simulates. 

In the case of the fibromyomatous sarcoma there are two points 
specially deserving attention : (a) the rapid growth at or about the meno- 
pause of a tumour previously known to exist, and (b) a more marked 
anaemia and deterioration of health than is ever found associated with 
the same stage of growth of a benign tumour. 

The growth of the tumour may be so rapid as to suggest the French 
designation grossesse cancereuse sometimes applied to such cases ; and, 
however smooth and symmetrical the tumour, the early occurrence of 
fixation, as compared with cancer, is a point of some diagnostic value. 

The profuse sero-sanguinolent discharge, like hydrorrhoea from 
sloughing fibroid but usually more turbid even before interference, may 
excite suspicion. The greater or less density or softness or sense of 
resistance conveyed on palpation of the tumour does not afford auy 
help to diagnosis. 

Attempts to diagnose the mucous form at a comparatively early stage 
by means of scrapings for microscopic examination have strikingly failed. 
It will be remembered that when arguments for and against total extirpa- 
tion were being eagerly sought foir in the early days of the controversy, 
Abel and Landau discovered that the endometrium of a uterus affected 
by malignant disease, even of the vaginal portion, was the seat of sar- 
comatous degeneration. The discovery was hailed as important, and 
its truth was supported by numerous observations. It is now, however, 
universally admitted that the appearances described are due to changes 
resulting from congestion of the endometrium, and that similar changes 
occur in the corporeal mucosa of the fibroid uterus. 

Prognosis. — There is a remarkable difference of opinion among 



MALIGNANT DISEASES OF THE UTERUS 729 

writers on the subject as to the comparative unfaYOurableness of the 
prognosis in sarcoma and in carcinoma. 

All are agreed as to sarcoma that it is malignant ; no patient once 
affected ever recovers. 

It is said by some to be slower in its development in the earlier stages 
than carcinoma, and when treated by early operation to be less likely to 
recur than carcinoma. A^ AYinckel commits himself to this opinion, but 
adds that if operation be impossible the disease is generally more rapidly 
fatal than carcinoma. This implies that the later stages of inoperable 
sarcoma are more rapid than in carcinoma, although the earlier develop- 
ment is slower. Eeports of individual cases do not seem quite to sup- 
port this symmetrical generalisation. 

]\Iost are agreed that if surgical interference is once begun, the down- 
ward course is rapid if the uterus and affected area be not completely 
swept away. The reported exceptions are comparatively few, although 
some of them are striking In recent years, when much attention has 
been devoted to radical surgical measures, a tolerable consensus of opinion 
has been formed to the effect that sarcoma recurs sooner than carcinoma 
after extirpation. 

Treatment of Sarcoma. — The treatment is radical or symptomatic. 
The radical treatment is the same as for carcinoma. If the uterus be 
movable, and there be no metastases or invasion of the vagina, the treat- 
ment is total extirpation. This should be done by the vaginal method if 
possible ; if this be impracticable, then by the combined abdominal and 
vaginal methods. If there be infiltration of the sacro-uterine folds or 
broad ligaments, even though extirpation is still possible, the advantages 
obtained in operating at so late a period in carcinoma are not to be ex- 
pected. Eecurrence takes place all the sooner, and the progress of the 
disease afterwards is so much the more rapid. 

V. Adenoma Malignum. — The question whether adenoma malignum 
should be considered a distinct class of cancer of the uterus is not yet set- 
tled. Such observations as have been published tend to the conclusion that 
it is a definite form of disease ; just as epithelioma is a definite form of 
malignant disease of the cervix : and the separate study and description 
of it would more rapidly bring about its elucidation and more effective 
treatment. 

It is a post-climacteric form of malignant disease almost restricted to 
the body of the uterus. It is too early in the history of the subject to 
generalise, but it may be safer and more useful in practice to assume 
that adenoma occurring in the body of the post-climacteric uterus is 
alwa^'s a malignant disease, and ought to be treated as such. 

Take as an illustration the case of a patient, age 57, married twenty- 
six years ; never pregnant ; menopause in her 49th year. For several 
years a history of slight discharge without colour and without offensive 
odour. The family doctor, several years ago, removed a small bunch of 
slimy polypi that projected from the os uteri; after which there was 
some diminution in the discharge. In 1893, the discharge had become 



730 SYSTEM OF GYNECOLOGY 

SO profuse that the patient again consulted her doctor. There was slight 
occasional haemorrhage also, though the amount of bleeding was never an 
important feature among the symptoms. The doctor sent her to consult 
a well-known gynaecologist, who spoke of some important operation, and 
on the patient's return home the uterus was dilated and curetted, some 
more polypi being removed. After this operation the discharge never 
ceased, and it was sometimes very profuse. After several months of 
'' convalescence " at the sea-side she returned home much worse in 
health, and I had the opportunity of examining her soon after. The 
discharge had usually been thin and somewhat slimy, and only quite 
recently had it become at all offensive in smell. 

From the history obtained at the first interview, and the character 
of the discharge (to the touch it felt like thin ovarian tumour fluid), I 
concluded that it was a case of malignant disease of the body of the 
uterus, and total extirpation was suggested. Before operation, however, 
a much better opportunity of examining the patient was obtained ; and, 
although, on superficial observation, the cervix uteri appeared intact and 
healthy, there was a peculiar dark coloured, velvety condition of the 
endometrium of the cervix: on passing a surgical probe cautiously 
through the os internum the body was found to be enlarged, and the 
probe could be felt to penetrate the tissues round the cavity. The 
operation, which was extremely difficult owing to the narrowness of the 
vagina, was accordingly performed in November 1894, and a year later 
the patient was described as having been completely restored to health. 

Microscopic examination of the uterus showed the muscular tissue 
penetrated everywhere — in some parts almost to the peritoneal covering ; 
but in considerable patches near the cavity, where the neoplasm had not 
completely ulcerated, the characteristic glandular appearance of malig- 
nant adenoma could be very definitely made out. 

The first case of adenoma of the body of the uterus was described 
by Matthews Duncan, and is quoted in full by Sir John Williams in 
his work. The chief points to be noted are : the patient, a virgin ; her 
age, 52 ; previous length of illness, two years ; and some uterine symp- 
toms. There is a history of previous good health ; then a copious red, 
watery discharge ; later, haemorrhage and the passing of fleshy pieces ; 
the discharge continued without intermission and was not foetid. 
There was pain in the back, then irregularly severe pain in the ab- 
domen, and still later great deterioration of the general health. Then 
follows a description of the condition of the uterus, the naked-eye ap- 
pearance of the growth, and the method of treatment; and then the 
author expresses the opinion that " it will, before many months are past, 
show the terrible characters of undoubted cancer." This prediction was 
soon fulfilled. The microscopic appearance was obscured by haemorrhage 
into the tissues of the parts removed, but it showed canals lined with a 
continuous stratum of cylindrical epithelium. Other details are given, 
such as we read in more recent observations made in material obtained 
by extirpation, and therefore more favourable for examination. 



MALIGNANT DISEASES OF THE UTERUS 731 

We have little definite knowledge about adenoma malignum as dis- 
tinguished from carcinoma of the body of the uterus. It could hardly be 
otherwise. Our knowledge of cancer as affecting the body of the uterus 
does not extend back much more than twenty years, when its very 
existence as a primary disease was still a subject of controversy. 

The material obtained by hysterectomy enabled Euge and Yeit (40) 
to produce their celebrated essay on cancer of the uterus, based on exact 
clinical and anatomical observations of twenty-one cases. Since then 
vast additions have been made to the literature of the subject, and more 
exact observations show that cancer of the body is of more common 
occurrence than was formerly supposed. Sir John Williams, at the time 
his w^ork was published in 1888, had seen only seven cases in all his 
experience ; whilst Schmidt (46), in the most recent account of work in 
a German clinic, gives nine cases of cancer of the body, including two 
of sarcomatous degeneration of myoma out of a total of 39. 

How many of the cases described as cancer of the bod}^ were malignant 
adenoma it is impossible to say, as very few observers have given suffi- 
ciently exact descriptions of the histology ; and those who have observed 
and described exactly are divided in opinion as to the proper term to 
apply to it — whether malignant adenoma or adeno-carcinoma. By its 
symptoms it has not been differentiated from cancer of the body, although 
some of its characters are sufficiently well marked. 

Euge (42) maintains that the benign form is a mere product of 
inflammation ; it is an endometritis glandularis hypertrophica, whilst 
the malignant form is closely related both clinically and anatomically 
to carcinoma. Ziegler calls it adenoma destruens, but ranks it among 
the carcinomata. 

Fiirst described a case of adenoma of the cervix, which was treated 
by the curette and Pacquelin's cautery. In a year and a half after- 
wards carcinoma of the body of the uterus had developed itself. He 
compared the simple glandular hyperplasia with the destructive form, 
and concluded that the latter shows its malignant character comparatively 
early by invasion of the deeper structures, and by the gland tubules 
assuming an irregular form with increase of their epithelium. In 
every such case he would extirpate the uterus, relying entirely on the 
microscopic appearances. 

This case points to the development of genuine carcinoma from 
typical adenoma; just as we find that recurrence after epithelioma of 
the portio vaginalis may show itself as true carcinoma. The argument 
that adenoma is therefore only a form of carcinoma applies with equal 
force to cancroid of the portio vaginalis. 

Hofmeier maintains that adenoma malignum should be placed in a 
separate category from carcinoma. He calls attention to the facts of its 
development. It consists of tubules of cylindrical epithelium which may 
lie side by side, or form coils by twisting about one another with little 
or no connective tissue layer intervening. It penetrates and destroys 
the underlying parenchyma, and recurs after operation. He accepts the 



732 SYSTEM OF GYNECOLOGY 

statement made by another observer that the benign form does not 
invade the underlying uterine muscle ; and that an important fact for 
diagnosis lies therein. 

His statements are largely controversial in reference to Euge and 
Veit, on the one hand, and to Abel and Landau on the other ; and they 
depend chiefly upon his belief in microscopic diagnosis. The important 
clinical characters, and the local tissue changes which differentiate it from 
carcinoma, have been, however, described nowhere better than in a case 
reported from Wtirzburg by Landerer. This was clearly a case of 
adenoma malignum, although the author holds on throughout to his pre- 
conception as to cancer. The patient was a married woman, set. 48 
years ; had borne five children, the last fifteen years before ; for many 
years menstruation had been irregular, and for four years she had suf- 
fered from almost constant coloured discharge. ISTo pain or subjective 
symptoms. On examination (April 1891) the uterus was found enlarged 
to the size of a man's fist ; it presented some irregularities in form and 
resistance ; the sound, passed over four inches, indicated soft masses and 
projections, and great congestion of mucosa. Portio vaginalis normal, 
multiparous. Abrasion of the mucosa with curette proved it vastly 
hypertrophied and softened : two teaspoonfuls of shreds of tissue were 
thus obtained. Microscopic examination led to diagnosis of endometritis 
glandularis hypertrophica. 

Some futile treatment followed. Temporary cessation of haemorrhage ; 
relapse and readmission to hospital, December 1891. Patient suffering 
then from pain to some extent, loss of flesh and failure of strength, 
and extreme anemia. Cervical part examined ; still apparently normal : 
corporeal part large, hard, nodular, and congested, but perfectly movable. 
Eepetitiou of curetting, microscopic examination of debris, and report 
with much circumstance. Kesult : Diagnosis of endometritis chronica 
glandularis hyperplastica, which condition was assumed to be produced 
by the presence of a myomatous interstitial tumour. Patient sent out 
with prescription for hydrastis canadensis. 

Eelapse once more ; haemorrhage, general pain, great loss of strength, 
anaemia. Author regretted that there was not a third curetting, zu diag- 
nostischen Zwecken; but total extirpation was resolved on, and carried 
out on March 31, 1892 — that is to say, after five years of haemorrhage 
and one year of treatment. Patient recovered. 

There is the usual prolix description of the macroscopic and micro- 
scopic appearances of the uterus. There was not a nodale of myoma 
anywhere, but there was great hypertrophy of apparently normal mus- 
cular tissue, with occasional small cysts disseminated through it, and there 
were polypous projections from the walls into the cavity of the uterus. 
Histologically the growth of gland cells was the most prominent feature ; 
the deep layers of the mucosa showed that sometimes the epithelium 
assumed the form of papillae springing from the gland cavity, and some- 
times a striking palisade-like arrangement of long, narrow, and closely- 
set cylindrical epithelium. Apparently without connection with the 



MALIGNANT DISEASES OF THE UTERUS 733 

mucosa there were lying throughout the whole muscular layers of the 
uterus islands of a tissue exactly resembling the mucous lining in struct- 
ure. . . . These islands were really connected by long, narrow, glandu- 
lar tubules, which broke through the muscular layers, and then formed 
gland-like coils of tubes. In the small cysts the papillary projections 
have, according to the description, exactly the histological form and 
appearance of the " mucous polypi " seen at the os externum in either 
young or old women. The author proceeds to remark that the whole 
mode of extension is in contrast to that of the ordinary form of cancer 
of the body, which we designate alveolar. It is altogether a special form. 
In adenoma the cancerous glands in a loose open fashion break through 
the neighbouring tissues ; the form of extension is almost dendritic. In 
alveolar cancer, on the other hand, the process is hardly ever diffuse ; it 
leaves large portions of the uterus intact, and invades the contiguous 
tissues continuously from the mucosa outwards. The author finally calls 
attention, as others have done, to a feature which is more or less charac- 
teristic of the rapid growth of epithelial elements in adenoma ; namely, 
the rapid development of the palisade-like arrangement of a long, 
narrow, closely-planted cylindrical epithelium. With the name adenoma 
benignum we must become accustomed to associate the idea of a tend- 
ency to take on malignant action, so that the epithet " benign " becomes 
merely a term of self-comfort and indecision. 

Landerer refers to a separate cystic space in the uterine wall in 
advance of the general invasion as a metastasis. Cases have been re- 
ported in which genuine metastases occurred in the lungs and liver, in 
Avhich recurrence, as carcinoma, took place in the cicatrix after total 
extirpation of the uterus, and in which the disease ran a much more 
rapid course than that which is almost characteristic. 

In the inchoate state of our scientific observations of this disease, and 
the consequent unripe condition of our knowledge, it would be altogether 
premature to attempt an}' exposition of the subject under the usual heads 
of pathological anatomy, course and symptoms, diagnosis, and so forth. 
We see the chief points in the cases quoted : the usual advanced age of 
the patients, the insidious beginning and chronic course, the absence 
of foetor and other characters of the discharge, the usual occurrence of 
haemorrhage, and later the development of the symptoms and of the 
general condition of health are characteristic of cancer of the body of the 
uterus. 

From incidents in the history of treatment we may also reflect, not 
without advantage, on the fatuity of comforting ourselves with a jargon 
of nomenclature, such as senile endometritis, fungous endometritis, 
diffuse benign adenoma, or even endometritis chronica glandularis 
hyperplastica, as applied to post-climacteric activity in the uterus. 

All activity of the endometrium in post-climacteric women which is 
not completely accounted for by other ascertainable causes should be 
looked upon as malignant. When so-called soft mucous polypi occur they 
may be removed, their seat of origin may be destroyed by operation, 



734 SYSTEM OF GYNECOLOGY 

and then, owing to the chronicity of the disease, the case is lost sight of 
and the disease is believed to be cured. The disease may occasionally 
develop before the menopause, but all post-climacteric polypus or fungus 
of the endometrium of thq body of the uterus is adenoma malignum. 

VI. Deciduoma Malignum. — This disease of the uterus, which has 
received much attention in recent years from German and French gynse- 
cologists and pathologists, is by reason of its rapidity of local growth, 
and tendency to metastases, the most malignant of all known maladies. 
To M. Sanger (43), of Leipzig, is due the credit of first calling attention 
to this disease, to which he applied the name given above. He main- 
tained that the tumour described by him was malignant, and consisted 
of decidual or placental elements so characteristic as to distinguish them 
from any other form of tumour found in the uterus. Later he spoke of 
it (44) as "an entirely new type of decidual tumour," which had been 
recognised in the malignant metastases forming deciduoma or decidual 
sarcoma. In 1893 Sanger (45) published his observations and opinions 
in a more complete form, including a review and criticism of the cases 
published meanwhile by other gynsecologists. He then gave up the name 
"deciduoma malignum," and adopted '-sarcoma deciduo-cellulare," to 
indicate his view of the origin of the tumour. Subsequent controversy 
would appear to suggest that this change was rather precipitate. 

Sanger's own case is given in detail as follows : — 

A woman married four months, in consequence of an accidental 
stumble in leaving a railway carriage, had an abortion in the eighth 
week of pregnancy. The ovum was not completely expelled, and she 
suffered from profuse haemorrhage for three weeks. In the fourth week 
a foul-smelling discharge from the uterus began, with accompanying high 
temperature. When Sanger was called in he found the patient very 
anaemic, with all the marks of retention of putrid parts of the ovum, and of 
septic absorption. The uterus was cleared of its contents after dilatation 
with laminaria tents ; the temperature then fell, the bleeding and foul 
discharge also ceased, but the pulse never came down to 100. The 
general condition of the patient did not improve much, and five months 
elapsed before she could leave her bed. The convalescence was hindered 
by a diffuse mass of parametritic exudation in front and to the left of the 
uterus. This gradually disappeared without corresponding improvement 
in the patient's health. The uterus remained large, but the abdomen 
was flat, and there was no trace of peritonitis. There was never any 
purulent discharge from the pudenda. Soon the patient had to take 
to bed again, owing to a return of the fever and pain in the left hypo- 
gastrium. Then there appeared in the right iliac fossa a tumour about 
the size of a goose's ^%^\ this tumour Avas soft, elastic, and tender on 
pressure. It was at first supposed to be an abscess, resulting from septic 
infection ; and the enlargement of the uterus, which was now distinct, was 
attributed to the same cause. The patient was admitted to hospital, and 
an incision was made into the swelling. Instead, however, of the expected 



MALIGNANT DISEASES OF THE UTERUS 735 

pus, the spongy, fungous substance of a tumour appeared, and a handful 
of it was cleared out with the fingers and sharp spoon. At the bottom 
of the cavity the bone was found to be denuded of periosteum. Micro- 
scopic examination showed that the masses consisted of round cells with 
large nuclei, together with a small amount of spindle cells and blood- 
clot. Tubercle bacilli were not found. The patient was transferred to 
Professor Thiersch for further operation, but owing to her general con- 
dition, with new symptoms including cough and dyspnoea, nothing was 
done. The uterus increased to the size of a four months' pregnancy, 
while the patient became greatly emaciated, and she died seven months 
from the onset of the symptoms of abortion. The post-mortem examina- 
tion, which was made by Professor Birch-Hirschfeld, gave some sur- 
prising results. The uterus was found to be the seat of several tumours, 
which were at first regarded as sarcoma teleangiectodes ; and there were 
metastases in the lungs, diaphragm, ribs, and elsewhere. The uterine 
mucous membrane Avas smooth throughout; and this point is of the 
greatest interest in comparing Sanger's case with others subsequently 
published. Microscopic examination led Sanger to the conclusion that 
his case was one of malignant deciduoma not hitherto described ; and 
from the opinion which he formed of its origin in the cells of the decid- 
ual connective tissue he classed it as a form of sarcoma. 

Contributions to the phenomena and pathology of the new disease 
soon began to appear. The first case we find in which the disease was 
diagnosed during life, and an attempt made to cope with it, is that of 
Gottschalk (12). 

The clinical facts show that haemorrhage began in February, in a case 
of abortion at two months, and the curette and tampon were repeatedly 
used during the whole summer as haemorrhage recurred; it was not 
until the 10th of August that the operation of extirpating the uterus was 
carried out as a last resource, " in spite of the deplorable condition of 
the patient." Gottschalk formed the opinion that the placental villosi- 
ties had undergone a process of malignant degeneration. The cellules 
of the serotina had become infected with the sarcomatous virus ; and a 
foetal tumour had been, as it were, injected into the maternal tissues, 
producing destruction of the uterine wall. 

These are early representative incidents in a discussion which has been 
proceeding for several years, and to which many addresses and written 
papers have been contributed. Concerning much of the published material 
it is not too harsh to describe it as " arid," with a Prench reviewer, who 
had evidently suffered under it. The most recent contribution to the 
literature of the subject of deciduoma malignum appears to be the report 
of the proceedings of the Berlin Gynaecological Society ; and we may 
now ask whether any facts stand clearly and definitely out after the cloud 
of words has cleared away ? Is there anything in it worth our knowing ? 
The answer must be that there has been a definite addition to our know- 
ledge, and as far as practical gynaecology is concerned the matter is settled. 
The controversy among the pathologists appears to be only well begun. 



736 SYSTEM OF GYNECOLOGY 

Pathological Anatomy. — The characteristic feature which gives to 
decidiioma malignum a special place among the new growths is the 
presence of giant cells grouped in a particular way, and endowed with a 
power of reproduction which is almost or altogether unique. These cells 
are also found in the secondary growths, where they present exactly the 
same appearance and relationships. The tumour is produced by an 
abnormal proliferation of these giant cells of the decidua ; but its bulk 
is also largely made up of a cellular tissue resembling sarcoma, and the 
cells of this class are found around the tumour invading and infiltrating 
the normal tissues of the organ affected. The giant cells have been 
carefully studied in their forms, grouping, and method of increase; and 
have been divided by ISTove-Josserand and Lacroix into three categories, 
though the authors admit that there are numerous anomalous and inter- 
mediate forms. The presence in the best examples of deciduoma malig- 
num of a considerable proportion of sarcoma-like substance has led to the 
inclusion of cases in this group of new growths which really belong to 
pure sarcoma ; and from this confusion has arisen much of the controversy. 

The characteristic structure of the tumour is the layer, seen on sec- 
tion, which lies between the necrosed tissue lining the uterine cavity 
and the genuine uterine substance more or less altered by the reaction 
produced by invasion. In addition to its special cell formation this 
portion of the tumour is extremely vascular ; hence the profuse hsemor- 
rhages which are so constantly referred to in the clinical history of each 
case. It is here that in some cases the villous arrangement can be 
observed, which in appearance suggests the chorionic villi; hence the 
division of the cases into two groups by Sanger, and the name chorio- 
deciduoma malignum proposed by Gottschalk, The dendritic form in 
this malignant disease has been ascribed to a myxomatous degeneration 
of the villi, largely on the ground that the genuine deciduoma malignum 
is so often seen after hydatid mole pregnancy ; but several competent 
pathologists, who have carefully examined the tumours formed after 
hydatid mole, have failed entirely to find any trace of the villous 
arrangement. 

The ultimate facts concerning the point of departure of these growths 
have given rise to much controversy, and are by no means settled. 

The opinions of Marchand (30) have been received with the greatest 
favour, and may be concisely stated. 

a. All the cases are essentially of the same nature, although they 
present individual differences owing to varying conditions in the history 
of their development. 

h. All the tumours are epithelial, the tissues combining in their 
formation being (a) the syncytium, that is, the uterine epithelial layer 
of the chorion ; (/3) the elements of the so-called cellular layer (layer of 
Langhans), that is, the ectodermal epithelium of the chorion. 

c. The two orders of elements form a normal constituent of the 
serotina. 

d. The derivatives from the syncytium take different forms : (a) 



MALIGNANT DISEASES OF THE UTERUS 'jyj 

very large cells with large nuclei rich in chromatine ; (6) protoplasmic 
masses with multiple nuclei ; (c) trabecular and retiform multinuclear 
structures which are surrounded by blood-spaces, and which hold the 
same relation to these as the syncytium does to the intravillous spaces. 

e. The elements of the cellular layer (of the ectoderm) most fre- 
quently occur as polyhedral clear cells containing glycogen. They 
multiply by indirect division of the nuclei. They vary in size, but are 
usually smaller than those of the syncytium. 

/. Hydatid mole pregnancy favours the occurrence of malignant neo- 
plasms, inasmuch as the epithelial elements penetrate the serotina more 
deeply than in normal pregnancy. 

g. The decidua cells, properly so-called, do not participate in the 
formation of the malignant neoplasms, or only in a very small degree at 
the primary site of origin. 

li. No participation of the connective tissue of the chorion in the 
formation of the malignant neoplasm has yet been demonstrated. 

^. The formation of metastases from these tumours proceeds almost 
invariably by way of the blood-vessels. 

Marchand having convinced himself that these malignant tumours, 
designated "deciduoma" and "sarcoma deciduo-cellulare," are really 
epithelial growths, proceeds to show cause why he should not adopt the 
obvious alternative in nomenclature, and call them carcinoma. He pro- 
poses, therefore, the term " serotinal tumour" as the most suitable. 

Marchand's exposition of his. views is sufficiently clear, and he 
appears to have brought some sort of order into the chaos of opinion 
existing among his colleagues. A timely contribution by him (29) to the 
structure and pathology of hydatid mole has also done much to clear up 
the confusion. 

Course and Symptoms. — When we come to consider the symptoms 
and course in a typical case of the disease in question we are on surer 
ground. It is a disease sui generis. All experience proves that cancer 
of the body of the uterus is a disease of elderly women. The average 
age in twenty-six cases of deciduoma malignum was 33-7 years. 

The first symptom is haemorrhage coming on soon after parturition at 
full term, or after interruption of pregnancy, especially of hydatid mole 
pregnancy. Almost invariably the haemorrhage has been attributed 
to retention of products of conception, a natural enough mistake until 
after the first curetting, not afterwards. Rarely as the disease occurs, 
it should always be suspected as the cause of haemorrhage after the 
apparently complete expulsion of a hydatid mole. This cause of abortion 
was the immediately preceding fact in about half of all the cases reported. 
In one case, at least, it was only the facts ascertained by the microscopic 
examination of an extirpated uterus that led to the inquiries which com- 
pleted the clinical history of hydatid mole pregnancy as immediately 
preceding the appearance of symptoms. Nove-Josserand and Lacroix 
have endeavoured to prove that the haemorrhage presents certain constant 
characteristics. It is certainly more profuse than the haemorrhage usually 

3b 



738 SYSTEM OF GYNECOLOGY 

occurring after abortion ; the patients become excessively anaemic, and 
in some of the cases reported death was mainly due to the loss of blood. 

The next symptom which appears comparatively early is profuse 
foetid discharge. It is a dirty-water, sanguinolent fluid, which persists 
even after haemorrhage has been temporarily suppressed by the use of 
the curette and other measures. 

Deterioration of the general health now comes on rapidly ; the patient 
becomes cachectic looking, can take no food, and soon loses flesh to a 
serious extent. She has all the appearance of suffering from malignant 
or advanced wasting organic disease. 

Physical examination usually reveals the fact that the uterus is larger 
than normal and freely movable. In more advanced or neglected cases 
bimanual examination may bring out the fact that there are irregularities 
about the uterus or in the vagina due to secondary growths. Dilata- 
tion of the uterine canal will enable the medical attendant to ascertain 
the presence in the uterus of soft friable masses of vegetating tissue, 
like placental debris, mixed with more or less changed blood-clot. The 
tumour may be dilf ase, but it is usually distinctly localised and attached 
to the wall of the body of the uterus. This fact distinguishes the case 
from one of retained shreds of placenta, membrane or blood-clot. Some 
have described the site of attachment after the removal of the tumour 
as giving the impression that the uterine wall was almost or altogether 
perforated. This appears to prove invasion of the wall of the uterus by 
the neoplasm. 

When the case has become fairly advanced metastases invariably 
occur, and give rise to symptoms connected with the organ or organs so 
affected. In most cases lung symptoms arose, sometimes in such a marked 
form as to suggest pulmonary tubercle. In Gottschalk's case the lung 
symptoms were urgent before operation; but they afterwards so far 
improved as to suggest that they must have been sympathetic. The 
patient, however, died in a few months from widely diffused secondary 
growths. 

In the course of the undecided treatment described in some cases local 
inflammation followed by septicaemic symptoms was observed, so that 
it must have been difficult or impossible to say whether the patient died 
from the original disease or from septicaemia. 

An account of the clinical characters of such a disease as deciduoma 
malignum with its rare occurrence and recent history would not be com- 
plete without some illustrative cases. 

Menge's case (31), from the University Hospital for Women of Leipzig, 
is fairly illustrative of the disease under consideration, and from the clini- 
cal point of view it is instructive. In December 1892, admission to the 
hospital of patient, aet. 35, pregnant six months, with uterine haemorrhage ; 
thirteen days after admission, expulsion of hydatid mole with assistance of 
manipulations of uterus ; shreds of tumour left in uterus, causing haemor- 
rhage ; rise of temperature to 103-5° ; no treatment or interference. Eight 
days after abortion examination re vealed"lochiometra"; insertion of index 



MALIGNANT DISEASES OF THE UTERUS 



739 



finger into cervix to effect relief. On 8th January patient left hospital. 
In May an attack of haemorrhage from the uterus occuwed, for which the 
patient was treated at home by curetting. On 7th July admission again 
to hospital on account of pain and haemorrhage. Dilation by tents and 
removal of nodules of tumour with finger and curette. Material thus 
obtained thrown away without examination. Rise of temperature to 
104°. Patient sent home 16th July. Three weeks later patient again 
brought into hospital after almost fatally profuse haemorrhage. Next 
day, after dilatation by tents, removal by sharp curette of large masses 
of placenta-like substance from body of uterus. Patient extremely 
anaemic. Temperature immediately after operation over 104°, after 
which rapid fall. Nodules removed subjected to careful examination. 
After delay of another week total extirpation resolved on and carried 
out. During operation the author was ''very disagreeably surprised'' 
to find secondary nodules in the vagina. Unsatisfactory recovery ; 
rapid recurrence ; death of patient six months after operation. 

The special feature of this next case {o%^ was the length of time 
which elapsed between the mole abortion and the marked symptoms 
of malignant disease. The abortion occurred at about seven months, 
in May 1891 ; expulsion of hydatid mole, described by practitioner in 
attendance as amounting to from three to four quarts. Haemorrhage in 
the summer of 1891, but not regular menstruation. In February 1892 
foul-smelling discharge. In May 1892, when patient came under Lohlein's 
observation, there was a foul, blood-stained watery discharge ; os uteri 
open, with irregular friable masses projecting. The tumour masses Avere 
removed, and the patient improved. After six weeks, return of symptoms 
with fever. Total extirpation of the uterus after removal of " polypus " : 
good recovery. Patient reported well five months later. Examination 
of uterus and. tumour showed sarcoma structure with distributed nodules 
containing large " decidua-like cells." Lohlein considers the tumour 
exceptionally benign, but still within the category of sarcoma of the 
uterus, with a causal relationship to hydatid mole pregnancy. 

In the following contribution by Klein to the history of malignant 
tumours of the decidua from the Hoyal University Hospital for Women, 
of Munich, the author gives an account of what he considers to be a case 
of decidual sarcoma after hydatid mole pregnancy. The interest of the 
case, except as a warning, lies largely in the post-mortem examination 
and the material obtained from it, which was subjected to careful in- 
vestigation. The patient was a married woman aet. 27. She began to 
bleed in the last week of January 1893. The fundus of the uterus was 
then as high as the umbilicus. Haemorrhage from the uterus continued 
to 12th]March, although tampons were used almost daily, and a hydatid 
mole was then expelled. Haemorrhage and pain frequently recurred. 
After nearly two months more the uterus was curetted. Some improve- 
ment for a short time, then relapse, with complications. It was not till 
November that the patient was sent in a dying state into the hospital 
by the practitioner who had attended from the beginning of the illness. 



740 SYSTEM OF GYNECOLOGY 

The disease was found to have spread to the vagina and parametrium, 
and there were small metastatic areas elsewhere. 

One of the best reported and in other respects most satisfactory 
cases recorded is that of ISTove-Josserand and Lacroix, of Lyons, already 
referred to. 

The case, shortly stated, was as follows : — Married woman, setat 24, 
became pregnant the third time in 1892. In March patient's abdomen 
was about the normal size at full term. Haemorrhage for from six to 
eight Aveeks, then spontaneous expulsion of enormous hydatid mole. 
Patient well for a month, then recurrence of haemorrhage every few 
days. Sent into hospital, under Fochier, 5th June. Examination after 
dilatation and removal of some friable debris ; temporary cessation of 
haemorrhage. K.e-admission 10th July. Patient then losing blood from 
uterus profusely ; had become exsanguine and so weak that she could 
not leave her bed; evening rise of temperature. Vaginal hysterectomy 
12th July; recovery excellent. Patient reported well three months 
later. 

Histological examination gave results similar to those already pub- 
lished, with additional, but not essentially different details. In the 
"clinical study" of the disease the authors direct particular attention 
to certain peculiarities about the haemorrhages, which are intermittent, 
sudden, and profuse, endangering the life of the patient; and a metror- 
rhagic or serous discharge of small amount frequently occurs during the 
whole of the intervals. Tamponment only temporarily arrests the bleed- 
ing. Then the discharge becomes offensive, indicating infection of the 
uterine cavity. A rapid alteration in the condition of the patient takes 
place ; loss of flesh, weakness, pallor, and anorexia supervene. Physical 
examination shows the uterus to be more or less enlarged, and explora- 
tion of the cavit}^ at an early stage reveals the presence of a localised 
friable tumour. If this tumour be removed it is rapidly reproduced. 
There may be room for difference of opinion as to the details of the 
examination and the preparatory treatment recommended by Fochier ; 
but the main point, prompt total extirpation, a measure which must 
commend itself to all gynaecologists, is strongly enforced. 

Diagnosis. — Considering the marked character of the disease 
brought out in the cases recorded it will be obvious that there should 
now be little difficulty in any case which may occur. The main facts 
to keep in mind are : — 

1. The history of recent parturition probably following interrup- 
tion of pregnancy, especially of hydatid mole pregnancy. The exist- 
ence of decidua in the uterus is a condition essential to the development 
of deciduoma malignum. 

2. The symptoms of profuse haemorrhage which have recurred 
again and again to such an extent as to have made the patient ex- 
tremely anaemic. 

3. The occurrence of a foul-smelling, thin, watery, or sanguineous 
discharge, which continues in spite of such curetting as may have put an 



MALIGNANT DISEASES OF THE UTERUS 741 

end to the haemorrhage for the time being ; ansemia, with loss of flesh 
and deterioration of the general health, with a rapidity and to an extent 
beyond that which might be expected from the symptoms and the dura- 
tion of the disease. 

4. Such symptoms demand closer investigation, and it becomes 
necessary to explore the uterus ; it has become more or less enlarged, 
and when the uterine cavity has been dilated to admit the index finger, 
friable bleeding masses can be extracted and put under the microscope 
for differential diagnosis. The diagnosis, however, can be completely 
established by clinical facts alone. When the uterus has been explored, 
and the curette used once for all, if there be a recurrence of haemorrhage 
and foul discharge, there is also recurrence of a maliguant neoplasm. 

It is easy to criticise the treatment of some of the early cases by men 
who were placed in an extremely difficult position in dealing with a 
rapidly fatal malady which they could not- diagnose without the guid- 
ance of previous experience ; and there can be no doubt that the repeated 
use of the curette in order to bring away debris of a recurring malig- 
nant growth could only hasten the occurrence of metastases. But the 
mistakes appear to have been honestly recorded, and the experience all 
points to this, that the patient's life depends upon prompt diagnosis and 
prompt definite treatment. 

Prognosis. — The disease is rapidly fatal. The prognosis as to length 
of life depends upon the results of surgical treatment, and these results 
depend in their turn upon certain circumstances which have to be 
weighed : — 

1. There is the immediate danger from the operation of hysterectomy. 

2. The danger that secondary invasion has somewhere occurred, in 
which case all surgical measures will be in vain. 

The development of metastases appears to depend upon — (a) the 
degree of malignancy in the different cases ; (h) the lapse of time since 
the first symptoms appeared ; (c) the amount of stimulation or wounding 
of the uterus resulting from manipulations intended for treatment. 

There appears to be nothing in the previous individual health or 
family history of the patients to be considered. They are usually young 
and apparently healthy women with every expectation of life. The 
disease has some analogy to puerperal septicaemia, which beyond a cer- 
tain stage is absolutely fatal unless a definite course of treatment be 
pursued ; and fatal even in this case when far advanced. 

Treatment. — All experience points definitely to one method of treat- 
ment and to no other ; that is, total hysterectomy per vaginam, with the 
removal of as much of the ovaries, tubes, and broad ligaments as can be 
reached without producing undue danger of shock. 

Some recorded cases warn us against indecision and delay. We have 
seen how to arrive at a diagnosis : as soon as the diagnosis is settled on 
clinical grounds the operation should be carried out. It is painful to read 
of patient and doctors waiting for the pathologist's report while the 
clinical facts point with moral certainty to the diagnosis, and while the 



742 SYSTEM OF GYNECOLOGY 

disease is rapidly developing about the uterus, and perhaps also sending 
its elements of reproduction to distant parts of the body. 

Several cases are reported which warn us against the use of the tampon 
to arrest hsemorrhage in this disease ; and against the repeated scraping 
of the cavity of the uterus even after the discharge has become septic 
and the neoplasm is recurring. Bacon reports a case in which the plug 
was used repeatedly over a period of many weeks to arrest hsemorrhage 
after a hydatid mole pregnancy ; the curette was used six months after 
the symptoms appeared, and the patient died nine days after the opera- 
tion. The post-mortem diagnosis suggests a great deal. It was as 
follows: ^'Deciduoma of the right broad ligament and of the lungs; 
endometritis and suppurative salpingitis; diffuse purulent peritonitis and 
empyema (bilateral) ; " with other more general disorders. 

Such misfortunes and failures in treatment as are contained in the 
clinical records of this disease were inevitable in the case of the pioneers 
who had to grope on without the light of previous experience of so 
mysterious and terrible a malady as deciduoma malignum. They have, 
however, the satisfaction of knowing that they have placed the medical 
profession under a debt of gratitude by the faithfully detailed and honest 
accounts of their cases published for the guidance of others. Those of 
us to whom their records are open will be without their excuse if we fail 
to diagnose with precision, and to treat promptly and effectively any 
cases which may henceforth come into our hands. 

W. J. Sinclair. 



REFERENCES 

1. Abel. " Zur Technikder vaginalen Uterusextirpationen," Arch.fiir Gyndk. Bd. 
xlvi. H. 1. — 2. AuvARD. Traite pratique degynecologie,pA13. Paris, 1892. — S.Bacon. 
" A Case of deciduoma malignum," Ame?'. Jour, of Obstet. May 1895. — 4. Bernhardt. 
" Kurze Mittheilung iiber eine neue Beliandlung des inoperabilen Gebarmutterkrebses," 
Centralhlait fiir Gyndk. 1894. — 5. Buecheler. " Ergebnisse der vaginalen Total 
extirpation mit Peritonealnaht," ZeiUclirift fur Geb. unci Gyndk. Bd. xxx. H. 2, 1894. — 
(j. BuMM. Verhandlungen dor deutschen Gesellschaft fiir Gyndkologie, 1892, p. 360. 
— 7. Burkle. On the Condition of the Patient after Vaginal Extii^ation of the 
Cancerous Uterus. Berlin, 1892. — 8. Dlthrssen. Cent ralhlatt fiir Gyndk. p. 309, 
18-,4. — 9. Freund. " Indicationen und Techuik der abdominalen und vaginalen Total 
extirpation des Uterus," Verhandlungen der deutschen Gesellschaft fiir Gyndkologie, 
3893. — 10. Fritsch. Krankheiten der Frauen, 1894:. — 11. Fuerst. " Ueber suspectes 
und malignes Cervixadenom," Zeitschrift fiir Geb. und Gyndk. Bd. xiv. 1887. — 12. 
GoTTSCHALK. " Deciduouia malignum," Be?^. klin. Woch. 1893, No. 4. — 13. Griffith, 
W. S. A. " The Early Diagnosis of Cancer of the Uterus," Brit. Med. Jour. February 
1, 189(), p. 265. — 14. GussEROW. Bie Neubildungen des Uterus. — 16. Herman. 
"Early Diagnosis of Cancer of the Cervix Uteri," Brit. Med. Jour. 1894, p. 
1011. — 17. Hernandez. " Traitement du cancer de I'uterus gravide," Ann. d° 
Gynec. August 1894. — 18. Herzfeld. "Ueber die Sacrale Total extirpation des 
Uterus," Verhandlungen d-^r deutschen Gesellschaft fiir Gyndkologie, 1893. — 19. 
HoFMBiER. " Zur Anatomie und Therapie des Carcinoma Corporis Uteri," Zeit- 
schrift fiir Geb. und Gyndk. Bd. xxxii. 1895. —20. Josserand and Lacroix. " Sur 
le deciduome raalin," Annales de Gynec. 1894. —21. Kahlden. "Das Sarkom des 
Uterus," Ziegler's B^itrage zur path. Anat. Bd. xiv. 1893. — 22. Klein. "Fall von 
Deciduo-sarcoma uteri giganto-cellulare," Arch, fiir Gyndk. Bd. xlvii. H. 2, 1894.— 
23. Krukenberg. "Die Resultate der operationen Behandlung des Carcinoms und 



PLASTIC GYNECOLOGICAL OPERATIONS 743 

Sarkoms der Gebarmutter," Zeitschrift filr Geb. und Gyndk. Bd. xxiii. — 24. Kuestxer. 
Das untere Utennsegnient und die Decidua Cervicalis. Jena, 1882. — 25. Laxderer. 
"Eia Adenocarciuoin des Corpus uteri," Zeitschrift fur Geb. und Gyniik. Bd. xxv. 
18!)2. — 26. Leopold. Verhandlungen der deutschen Gesellschaft fur Gyndkologie, 1891 . 

— 27. Loehleik. •' Sarcoma deciduo-cellulare nach Vorausgegangem Mj^oma chorii," 
Centralhlatt fur Gyniik. 1893, — 28. Maxgiagalli. '" Risultate prossimi e remoti della 
istevectoinia vaginale per Carcinona," Annali di Ostetricia e Ginecologia, Xovember 
1894.-29. Marchaxd. " Ueber den Bau der Blasenmole," Zeitschrift fur Geh. und 
Gyndk. Bd. xxxii. H. 3, 1895. — 30. Ibid. '"Ueber die so-genaunteu ' decidualen ' 
Gescliwiilste, etc." Monat. f. Geburt. und Gyndk. Bd. i. H. 5, 6, 1895. — 31. Mexge. 
"Ueber Deciduosarcoma uteri," Zeitschrift fdr Geb. und Gyndk. xxx. 2, 1894. — 
32. MuLLER. " Zur Lehre von Carcinoma Uteri," Charite Annalen, 1892. — 33. 
Pfaxxexstiel. "Das traubige Sarcom des Cervix Uteri," Virchovfs Arch, exxvii. 
1892. — 34. Pick. " Zur Histogenese und Klassification der Gebarmutter sarkome." 
Arch. f. Gyndk. Bd. xxi. p. 24 ; and Whitridge Williams, "Contributions to tbe 
Histology and Histogenesis of Sarcoma of the Uterus," Amer. Journ. of Obst. vol. xxix. 
p. 721. — 35. Pick. "Zur Histogenese und Klassification der Gebarmutter," Arch. f. 
Gyndk. Bd. xlviii. 1894. — 30. Picor. Les grands processus niorbides, 1878. — 37. Quain's 
Anatomy, vol. iii. part iv. p. 266. — 38. Richelot. Archives generates de medecine, 
1892. — 39. Ibid. " Derniers re'sultats de I'hysterectomie vaginale," Annales de 
gyne'cologie, Dec. 1895. — 40. Ruge and Veit. Zeitschj-ift fdr Geburt. und Gyndk. Bd. 
iv. 1881. — 41. Ruge. "Das Mikroskop in der Gynakologie und die Diagnostik," 
Zeitschrift fur Geb. und Gyndk. Bd. 20, 1890. — 42. Ibid. " Ueber Adenom des Uterus," 
Verhandlungen der deutschen Gesellschaft, 1888. — 43. Saxger. Centralblatt fiir Gyndk. 
1889. — 44. Ibid, " Ueber Deciduome," Verhandlwig. der deutscheji Gesellschaft, 1892. 
— 45. Ibid. " Ueber Sarcoma uteri deciduo-cellulare und andere deciduale Gescliwiilste," 
Archiv fiir Gyndk. Bd. xliv. 1894. — 48. Schmidt. Centralblatt fiir Gyndk. Xo. 43, 
1895. — 47. ScHULTZ. " Des injections intraparenchymateuses d'Alcohol dans le traite- 
ment du cancer inoperable uterin," Nouv. Arch, d'obstet. et de Gyn. No. 10, 1894. — 48. 
SiMPSox. Clinical Lectures on the Diseases of Women, 1872. —49. Spiegelberg. 
" Casuistische Mittheilungen zu den Sarcomen des Uterus," Aj'ch. f. Gyndk. Bd. iv. 
1872. — 50. Terrier and Hartmax. "Immediate and Remote Results of Vaginal 
Hysterectomy for Cancer," Revue de Chirurgie, 1892. — 51. Theilhaber. " Die Behand- 
lung des Uteruscarcinomsin der Schwangerschaft undbei der Geburt." Arch, fiir Gyndk. 
Bd. xlvii. 1894. — 52. Thorxtox, J. Kxowsley. Address oti the Early Diagnosis of 
Milignant Disease of the Uterus, Brit. Med. Assoc. London, July 1895. — 53. Vulliet. 
" Ueber die palliative Behandlung des Uteruscarcinoras mit Alkoholinjektionen," Cen- 
tralblatt fiir Gyndk. No. 34, 1895. — 54. "Wells, Sir Spexcer. Morton Lectures, 1888. 

— 55. Williams, Sir JoHX. Cancer of the Uterus. — 56. Wixckel. Diseases of Women. 

— 57. WixTER. " Ueber die Recidive des Uterus Krebses," Verhandlungen der deutschen 
Gesellschaft fiir Gyndkologie, 1893. —58. Ibid. " Ueber die Schroeder'sche Supra vaginale 
Amputation bei Portiocarcinom," Zeitschrift fiir Geburt. und Gyndk. Bd. xxii. H. 1, 
1891. — 59. Zeitschrift fiir Geb. und Gyndk. Bd. xxxiii. 

W. J. s. 



PLASTIC GYNECOLOGICAL OPERATIONS 

The following lines will not contain a history of plastic gynsecic opera- 
tions. It appeared to me better to describe the methods adopted in 
modern gynaecology, than to recapitulate all the procedures recom- 
mended by the many writers of the past. 

Plastic operations in gynaecology may be conveniently considered 
under five headings : — 



744 SYSTEM OF GYNECOLOGY 

A. Those for inj iiries and lacerations of the pelvic floor, due directly 

to the process of parturition. 

B. Those for displacements of the pelvic floor, including prolapsus 

uteri, cystocele, urethrocele, rectocele, and vaginal enterocele. 

C. Those for laceration of the cervix, the result of parturition. 

D. Those for certain cervical deformities and inflammations. 

E. Those for repair of fistulous openings between the bladder or 

intestine and other viscera. 



A. OPERATIONS FOR INJURIES TO THE PELVIC FLOOR DIRECTLY DUE 

TO PARTURITION 

The anatomy of the pelvic floor may with advantage be given in a 
few introductory words. This is composed from within outwards of 
(1) a pair of broad and thin muscles (the levatores ani), which are the 
chief means of support of the pelvic viscera; (2) an arrangement of 
fasciae and muscles (more superficially situated), the components of 
which act as accessories. 

1. The levatores ani, with the coccygei muscles, form the true pelvic 
diaphragm : each levator ani arises from the pubes, the white line of 
pelvic fascia, and the ischiatic spine, and sweeping downwards, forwards, 
and inwards, by its anterior fibres becomes attached, from before back- 
wards, to the lower portion of the vagina, aiding in forming the lateral 
sulci ; by its middle fibres to the rectum, blending with the internal 
sphincter ; and by its posterior fibres to its fellow of the opposite side : 
the coccygei may be said to complete this pelvic diaphragm in its 
posterior portion. One of the chief functions of this musculature is to 
elevate the vagina and rectum, and to preserve the slit-like form with 
bilateral sulci which the former presents on transverse section. By the 
vaginal sulcus is meant the depression between the centre and side of 
the vagina which produces a kind of groove on each side. 

2. The most external covering of the pelvic floor is a layer of super- 
ficial fascia, itself a continuation of the general body fascia; beneath this 
is a deeper layer, and, finally, there is the so-called triangular ligament 
which consists of an anterior and posterior lamina filling in the pubic 
arch. Between the deeper layer of the superficial fascia and the ante- 
rior lamina of the triangular ligament three important pairs of muscles 
are found: (a) The transversus perinei. (/?) The bulbo-cavernosus. 
(y) The erector clitoridis. 

The perineum until recently was considered as a thick wedge-shaped 
body, partly muscular, partly tendinous, lying between the vagina in 
front and the rectum behind ; and materially aiding in the support of 
the uterus : we now more accurately regard it as a movable centre of 
attachment for the transversus perinei, the sphincter and levator ani, 
and the pelvic fascia ; as well as for the lower portion of the rectum and 
vagina. Thus the levator ani muscle, with the pelvic fascia, forms the 



PLASTIC GYNECOLOGICAL OPERATIONS 745 

true pelvic floor on which the viscera rest, and through which the rectum 
and vagina find their exit. 

The pelvic floor consists of two " segments " — an anterior or pubic 
and a posterior or sacral — separated by the vaginal slit or cleft ; the 
pubic portion is slightly drawn up, or remains stationary during labour ; 
Avhile the sacral is pressed down and stretched during the passage of the 
foetal head through the vulval orifice : hence it is that practically all the 
lacerations of the pelvic floor requiring repair are confined to the latter 
segment. These injuries are treated by certain operative procedures 
which may be immediate (that is, at the time of labour) or remote (that 
is, at some variable time after the accident, not earlier than eight weeks) ; 
this paper is devoted only to a consideration of the " remote " operations, 
as the " immediate " belong to the department of obstetrics. 

The lacerations of the pelvic floor fall into three classes : — 

i. Partial Rupture of the Perineum. — This consists of a median tear 
through the trans versus perinei and bulbo-cavernosus muscles, and the 
superficial fascia up to, but not into the sphincter ani. It is a frequent 
result of the passage of the vertex through the pelvic outlet in first 
labours. As a rule it is productive of no bad symptoms, but occasionally 
gives rise to a feeling of descent of the pelvic viscera, to entrance of air 
into the vagina, and other sensations of a less definite nature. ISTeither 
prolapsus uteri nor gaping of the vaginal orifice occurs as a result of this 
accident. 

On inspecting such parts in a woman, in the dorsal decubitus, who 
has been confined a sufficiently long time for complete cicatrisation to 
have taken place, it will be noticed that the vulval outlet is somewhat 
prolonged backwards, but is not patulous ; upon separating the labia, a 
kidney-shaped surface covered by shining mucous membrane (cicatricial 
tissue), paler than usual and without rugae, will be seen. The sites of 
the torn ends of the transversus perinei and bulbo-cavernosus cannot, of 
course, be detected. On being told to bear down there , should be no 
more than an ordinary descent of the uterus and vaginal walls, and the 
sphincter will be found intact. The lateral vaginal sulci will be present 
and, on passing the finger into each, the supporting band of fibres of the 
levator ani may be distinctly made out. The sacral segment will be in 
apposition to the pubic, as is indicated by the close application of the 
anterior to the posterior vaginal walls. 

ii. Complete Rupture of the Perineum. — This is a tear, usually 
median, through the perineum and internal sphincter ani. The patient 
suffering from this distressing condition has more or less complete incon- 
tinence of fseces and flatus, painful sitting-down, and not infrequently 
dyspareunia. The appearance of the parts after cicatrisation is some- 
what as follows : the anus is represented by an opening, the shape of an 
isosceles triangle ; the base of this triangle is formed by a concave 
corrugated surface — the posterior margin of the anus ; the sides are the 
edges of the torn recto-vaginal septum. The sphincter ani being com- 
pletely torn through, the ends have retracted, wrinkling the skin between 



746 



SYSTEM OF GYNECOLOGY 




Fig. 154. — Complete rupture of the perineum 

and the lower portion of the recto-vaginal pelvic faSCia 
septum. The anterior vaginal wall re- 
tracted by speculum. A band of cica- 



them ; their site is indicated by a small, almost circular, depression upon 
each buttock (Fig. 154). The mucous membrane of the rectum is red, 

inflamed, and prolapsed or everted ; it 
bleeds easily when touched, and se- 
cretes tenacious mucus. On introduc- 
tion of the finger into the rectum there 
is a want of grip, and the edges of the 
torn recto-vaginal septum are more 
clearly defined. The anterior and pos- 
terior vaginal walls are in apposition, 
and the lateral sulci intact, as in the 
former case. 

iii. Lacerations of the Pelvic Floor 
Proper. — These injuries are usually uni- 
or bilateral, and submucous, being pro- 
duced by a tearing through of the fibres 
of the levator ani, especially of those 
attached to the vagina, rectum, and 
It is only after the 
patient begins to get about that the 

tricial tissue passes obliquely across the rCSultS of thcSC laceratioUS are UOticcd. 

If the attachments of the levator to 
the rectum and vaginal sulci be torn through, the sacral segment 
is dragged backwards towards the coccyx ; the vulval orifice becomes 
elongated antero-posteriorly ; the vaginal walls are everted, and the 
vulval outlet patulous — the latter condition being recognised in ad- 
dition by the flatness of the crease between the buttocks, anterior to 
the anus ; and the recto-vaginal 
wall, instead of being concave, be- 
comes convex and protuberant, so 
as to produce a rectocele. The fin- 
ger inserted into the vagina will fail 
to detect the attachment of the le- 
vatores ani to the lateral borders of 
the lower portions of the vagina; 
it is probable that the fibres of the 
levator ani attached to the left vagi- 
nal sulcus are those most usually 
torn through, owing to the frequency 
of the first position of the vertex. 

Typical instances of classes i., 
ii., and iii. are very frequent, but it must be borne in mind that it is 
very common to meet with cases in which complete perineal laceration 
is combined with lateral rents of the levator ani : in such cases the 
physical signs would present a compound of those depicted under class 
ii. and class iii. 

It will be more convenient to consider together the plastic operations 



va 




Fig. 155. — Relations of levator ani to the rectum 
and vaginal walls ; normal condition. «, 
Urethra ; va, vagina seen in section as a 
slit, with s its right lateral sulcus ; r\ rec- 
tum ; I, levator ani muscle (vaginal fibres) ; 
I, levator ani muscle (rectal fibres). 




PLASTIC GYNECOLOGICAL OPERATIONS 747 

necessary for the cases in class i. and class ii. ; a full description of the 
technique to be adopted in class ii. will comprehend that of class i. 

No plastic operation should be 
carried out without full antiseptic ^. \ ^<^^^^^^^^^^^^^^;>\ ^-u 

precautions ; these are completely y&^ 0' 

described in Dr. Amand Routh's 

paper on "Gynaecological Thera- ^''' //^^MV_j>/ \M///MM\ Hi 

peutics," p. 249. /;/- 

Plastic Operation for Complete ;> 
Laceration of the Perineum 

(class ii.). — There is no procedure 

which, besides manual dexterity, Fig. 156.— Relations of levator ani to the rectum 
rpnnirp>^ p-rpatpr oatp in thp -nrp ^°^ vaginal walls; injured condition. A 

requires gieaiei Caie in Xne pre- deep tear through the vaginal and rectal fibres 

paratory and after treatment than producing eifacement of sulcus, and a patu- 

11 T • 1 , lous vagina, u. ra, s, r, as in Fig. 155: s\ 

perineorrhaphy; and m order to altered vaginal sulcus ; Z^„ torn rectal and 

describe it accurately, it is necessary vaginal fibres; Z,„ normal condition. (Dia- 

. , ,. . , ^, ^, . ... r, grammatic form below.) 

to subdivide the subject into tour 

headings : (a) Preparator}^ treatment ; (6) Denudation ; (c) Suturing ; 
{d) After management. A fifth procedure, namely, stretching of the 
lacerated sphincter, is often inserted between the first and second of 
these, and is certainly useful in some cases. 

(a) Preparatory Treatment. — The operation is performed under most 
favourable circumstances a week or ten days after the cessation of 
menstruation, and shortly after the patient's return from country or sea 
air. At least two months should have elapsed since the labour in which 
the injury was inflicted; the urine must be examined to ascertain the 
absence of albumin and sugar. If the woman be nursing her child it is 
better to wean it. For seven days the patient should be placed upon 
light diet — fish, eggs, and broth — and is better in bed, though this is not 
essential ; some observers forbid the use of milk as apt to produce constipa- 
tion. In order to get rid of all scybala from the large intestine, a pill 
composed as follows should be given every evening at bed-time for a 
week: — I^ Extr. aloes liq. gr. iss.-iiss., Pil. col. c. cal. gr. ij., Extr. 
cascar. sagrad. gr. iss., Extr. belladonnse gr. \ — the doses being so 
regulated as to produce two liquid motions daily. The night before the 
operation a full dose of ol. ricini should be administered, and a simple 
enema an hour before. For twenty-four hours immediately preceding the 
operation absolute rest in bed is necessary, and soup and barley water 
only as diet. During this week hot vaginal douches (temp. 110° to 
120° F.) of 1 in 4000 corrosive sublimate solution should be adminis- 
tered thrice daily ; these relieve congestion, soften the tissues, and pre- 
vent excessive venous oozing during the process of denudation. Should 
there be much leucorrhoea the douche may be followed by the introduc- 
tion of a glycerine pledget, which protects the irritated surfaces from 
the discharge. Some operators are accustomed, a few days previously, 
to divide subcutaneously those scars which appear to distort the parts. 



748 SYSTEM OF GYNECOLOGY 

and are likely to interfere with the healing process; this procedure, 
however, is open to question. 

Should the bowels have failed to act just before the anaesthetic is 
given, on its administration the rectum should be swabbed out, and any 
masses removed with the blunt spoon. 

As the rectum communicates directly with the site of the operation, 
strict asepsis is impossible ; at the same time contamination must be 
prevented as far as circumstances allow. The patient should lie in the 
dorsal position, with her knees supported and separated by a crutch ; a 
mackintosh sheet, over which is a towel soaked in 1 in 4000 mercurial 
solution, should be laid under the buttocks ; and a flat tray half filled with 
1 in 20 carbolic acid solution, and containing the necessary instruments 
(recently boiled) is placed within easy reach of the operator, who should 
have gone through the usual purifying process on his own person. 

Through a Sims' speculum the vaginal mucous membrane and the 
site of the rupture should be thoroughly and firmly rubbed over with 
cotton wool wetted with 1 in 1000 solution; the labia and parts about 
the perineum are shaved, and then purified, first with soap and water, 
afterwards with the perchloride solution. 

The instruments necessary for the operation are (1) six pairs of 
Spencer Wells' artery forceps ; (2) artery catch forceps ; (3) long 
dissecting forceps, preferably with hooked ends ; (4) a pair of sharp 
pointed angular scissors; (5) needles of various curves; (6) a needle 
holder, either Spencer Wells' or Hagedorn's, according to the needles 
in use. 

Some operators stretch the sphincter, others comdemn this practice ; 
among the latter is Emmet. The reason for stretching is that when the 
torn ends of the sphincter are sutured, the irritation from collection of 
flatus and the bruising of the parts during the operation are productive 
of much reflex muscular contraction, which must prevent firm union or 
seriously interfere with it. If stretching be done before suturing the 
muscle remains paralysed for forty-eight hours at least, and good union 
takes place ; moreover, after stretching, the ends of the contracted 
sphincter are more easily accessible. The manoeuvre is carried out by 
grasping the tissues firmly on one side, over the depressed end of the 
sphincter, with the thumb and first finger of one hand, and forcibly 
stretching the contracted muscle with the other ; this action is repeated 
on the other side. 

(6) Denudation may be carried out either by paring, that is, removing 
a superficial layer of mucous membrane with the knife or scissors in order 
to leave a bare surface, or by the method termed "flap-splitting." The 
latter process is now generally adopted, and must be carefully described. 

Thepatientbeingansesthetisedand lying in the dorsal position, the skin 
over the circular depressions (Fig. 157, s ,sj corresponding to the severed 
sphincter muscle ili) is seized with the hook dissecting forceps and slightly 
raised ; with the scissors this portion of skin, say on the right side, should 
be excised, a procedure which bares the torn end of the muscle and opens 



PLASTIC GYNECOLOGICAL OPERATIONS 



749 




7j 

Fig. 157. — Perineorrhaphy ; preliminary 
incisions. cZ, Clitoris ; u, urethral 
orifice ; l.m., labium minus ; a.v.iv., 
anterior vaginal Avail; p.v.rv., pos- 
terior vaginal wall ; k, retracted 
sphincter. (Diagrammatic.) 



up the cellular tissue. The same manoeuvre is carried out on the opposite 
side. The point of one blade of the scissors is now buried in the loose 
tissue at this bare spot on the right (opera- 
tor's) side (Fig. 157, s), and carried along the 
edge of the vaginal opening between the 
superficial and deep tissue, until a point is 
reached above the level of the apex of the 
triangle formed by the rent of the recto- 
vaginal septum (Fig. 157, a) : a few snips of 
the scissors will complete the incision ; a 
similar manoeuvre is carried out on the 
other side (Fig. 157, 6). Starting again 
from the denuded spot (s), the point of the 
scissors is carried along the edge of the 
recto-vaginal septum in the direction of 
the arrow, separating it into an upper and 
lower flap. A similar incision beginning 
at s^ meets this one at the apex of the 
triangle (c). If now the angles at s and s, 
be raised by catch forceps, and the scissors 
passed carefully into the cellular tissue, it will be seen how easily a 
flap is raised from the recto-vaginal septum (Fig. 158,/), leaving a raw 

bilobed surface. In Fig. 158 the flap has 
been raised, and it will be found that s 
and w, s^ and lo^ are corresponding letters 
on the bare surface and flap respectively : 
the first finger of an assistant's hand in 
the rectum aids very much in bringing 
the different parts under the action of the 
scissors. This flap may be now cut away 
if there be a redundancy of tissue, as is 
sometimes the case ; otherwise it is drawn 
up out of the way by a tenaculum and 
left to be dealt with later. The bleeding 
surface should be lightly swabbed over 
with small pieces of cotton wool dipped 
in 1 in 4000 solution and wrung nearly 
dry. Haemorrhage soon ceases, as a rule, 
owing to the pinching action of the 
scissors ; but if it continue, a hot douche of water at 110° F. should be 
played over the wound, and a sponge wrung out in water at the same 
temperature pressed upon it at intervals ; if a distinct bleeding vessel 
can be made out, it must be seized with a Spencer Wells' forceps, which 
will remain attached until the sutures are passed. 

(c) Passage of the Sutures. — The most suitable material is carbolic 
silk ; but silver wire, chromic catgut, and silkworm gut are also exten- 
sively used by their respective advocates : a silk suture appears to me 




Fig. 158. — Perineorrhaphy; denudation, 
Flap (/) raised by tenacula {t t,) ; k. 
cl, u, l.m., as in Fig. 157. 



750 



SYSTEM OF GYNECOLOGY 




Fig. 159. 



to have tlie greatest advantages. Two sizes are required — a very fine 
one for repair of tlie torn recto-vaginal septum, and a slightly stouter 
material for the perineum proper. 

Closure of the recto-vaginal rent may be performed in two ways : — by 
the " purse-string " suture, and by the interrupted " buried " suture. 

Fig. 159 illustrates the former method ; 
the point of a fine half curved needle, in 
its holder, enters the cut edge of the 
sphincter at the point 5 ; it is then passed 
up parallel with one side of the rent to 
the apex of the triangle c, brought down 
on the other side and out through the 
other cut end of the sphincter a. The two 
„ , . , , ends are tied tightly, so that the points a, 

Purse-string suture ; suture oy7 r 7 

a, b, Denuded ends of 0, and c are approximated, and the muscle 
sphincter; c, angle of rent. repaired. Failure in operations on the 

perineum is chiefly due to faults in passing the sutures ; hence it is of the 
utmost importance that the severed ends of the sphincter should be 
carefully brought together. The lat- 
ter procedure is more satisfactory, 
and consists in passing a series of 
sutures an eighth of an inch apart as 
shown in the diagram (Fig. 160). A 
needle threaded with very fine silk is 
passed through one edge (operator's 
left) of the rent from below ; it is 
then carried over the laceration, and 
through the edge on the opposite 
side, from above downwards, so that 
when tied the knot will lie in the 
rectum itself. Five of these sutures 
are generally necessary, each being tied before the next is passed ; the 
lowest is of the greatest importance, as by it the bulk of the sphincter is 




Fig. 160. — Perineorrhaphy; repair of the recto- 
vaginal septum. Sutures 2 and 5 are passed to 
show direction taken by the needle ; the sites 
of ingress and egress of the others are indi- 
cated by dots with a corresponding figure. 





7. 2. 

Fig. 161. —1. Section of torn sphincter (a), with suture {b c) properly passed. 2. Improperly passed. 



repaired (Fig. 160, 5) ; if the little finger be passed into the newly made 
anus as the patient recovers consciousness, it will be grasped tightly. 



PLASTIC GYNAECOLOGICAL OPERATIONS 751 

It is now seen that a somewhat renif orm raw surface is left, as in an 
incomplete rupture of the perineum already described, the repaired recto- 
vaginal septum forming a central vertical line in its lower part (Fig. 162) ; 
repair of this injury is extremely simple. The needle selected should be 
longer and stouter and the suture thicker than for the preceding step of 
the operation. The point of the needle is entered on the skin surface 
close to the raw edge, and pushed across the recto-vaginal septum be- 
neath the denuded surface, emerging on the skin on the opposite side. 
Three other sutures are passed in the same way (i. 11. iii. iv.). 

iSTothing further should be done ^Y 

until bleeding ceases; the Spencer ^"--^/r:::r7iriIlN.«-^^^-----^^X' 
Wells' forceps can now be taken off, / \ 

and if the surface remain fairly dry — '/ \' — ^^^ 

an antiseptic douche may be played I ^ i 

over the wound, and the sutures tied 3c^ S^ ~ 7^ 

or the wires twisted. Any blood '^'^N. -5-—^^ ^ 

flowing after the co-adaptation of the ^.^^*"^^^^^-*_^— — '^'"^^^^ 

flaps or clots may break down into pus ^ ^^^ ^ . ^ ^ 

\ • A 1 ^^'^- ^^-- — Perineorrhaphy; recto-vag-inal sep- 

and prevent union. As the sutures tum repaired, the four superficial or peri- 

are being secured the legs must be °*^^^ "^^^'"^^ p*^^«^' ^^^ °^* *^^^- 
brought together and tied at the knees. The sutures should not be 
tied too tightly ; practice only can enable the operator to gauge the 
proper amount of tension. Some local swelling always follows the 
operation. If at any part of the wound the edges are not quite in 
apposition, it is well to insert one or more superficial catgut stitches. 
The wound is now dusted over mth iodoform powder; the urethral 
orifice is shown to the nurse in attendance to enable her to pass the 
catheter, and a wood-wool diaper is applied by means of a T bandage. 
The patient is then put to bed on her back, or side, with her knees 
tied together and supported over a bolster. No morphia suppository is 
necessary, as the patient rarely suffers pain, and no agent likely to pro- 
duce constipation should be administered. 

In those cases in which it is not thought desirable to cut away the 
dissected-up flap, three or more sutures are passed through its sub- 
stances transversely, and it is, so to speak, longitudinally folded upon 
itself when these are tied. 

(cZ) Tlie After 3Ianagement. — Xo opium or alcohol should be given. 
If vomiting come on after the ansesthetic, the nurse should support the 
perineum with the palm of her hand flat upon the diaper. The catheter 
is necessary every six hours, great care being taken to avoid dribbling of 
urine over the wound ; the instrument when not in use should lie in 1 
in 4000 solution. Some operators insist that the urine should be passed 
naturally from the beginning, lest the bladder be infected from the use 
of the catheter. Xo food is necessary for at least twelve hours ; then 
only barley-water and milk, a teaspoonful at a time. Fluid diet only 
should be administered for twenty-four hours after the operation ; gruel 
and bread and milk may be given on the second and third days. A 



752 



SYSTEM OF GYNECOLOGY 



purgative of the same composition as that given before the operation 
must be administered on the evening of the third day, or even earlier ; 
some operators give an aperient within twenty-four hours. Castor oil is 
of great value, but is often objected to by the patient; the compound 
liquorice powder in 3j. doses is useful. A very efficacious plan is to 
give a teaspoonful of saturated solution of Epsom salts every half hour 
until the required result is attained. Flatus may be relieved by pass- 
ing a catheter into the rectum, keeping it carefully pressed along the 
posterior rectal wall during introduction. If, before the action of the 
bowels takes place, the patient be aware of a scybalon in the rectum, a 
small amount of olive oil may with great advantage be injected into 
the bowel through a No. 8 male catheter. 

After an action of the bowels the rectum should be washed out with 
a solution of boracic acid, to prevent contamination of the rectal sutures. 
It was formerly customary to keep the bowels quiet until the sixth 
or seventh day ; but it was found by experience that the scybala tore 
open the recently healed tissues. The object of the more modern treat- 
ment is to get early but liquid motions. ISTo antiseptic vaginal douches 
are necessary ; but twice daily the external genitals may be washed 
with a 1 in 4000 mercurial solution, and the gauze pad frequently 
changed to keep the wound dry. The sutures should be removed on 
the tenth day or before if they produce any irritation ; a distinct rise 
in temperature, with a sensation of throbbing about the parts, followed 
by a purulent discharge, indicates that suppuration has taken place in 
some part of the wound. 

Various modifications of the above method are in use, but of these 

two only need be described here ; namely, that of Hegar, who modified 

Simon's operation (the " Simon-Hegar "), and that of A. Martin of Berlin. 

I) ^^ Afterwards I shall describe 

~ Alexander Duke's mode of 

repair, which is on an en- 
tirely different plan. 

Tlie '^ Simon-Hegar^^ Op- 
eration for complete Perineal 
Rupture. — The principle 
upon which this method is 
founded assumes that the 
perineal body is torn on three 
surfaces, and that, to be suc- 
cessful in repairing the rent, 
sutures must be inserted on 
the vaginal, rectal, and ex- 
ternal perineal surfaces. 
The shape of the fresh- 
ened surface may be compared in shape to a butterfly, the recto-vaginal 
septum being the body, and a tongue-shaped projection (Fig. 163, c) 
the head. 




Fro 



-Perineorrhaphy (Simon-Heg'ar method of suture). 
a, Angle of recto-vaginal rent; d d„ sites of torn ends 
of lacerated sphincter muscle; c, central tongue denuded 
and two sutures, 1 1,, 2 2,, passed \ h h„ extremities 
of denuded surfaces on labia majora. 



PLASTIC GYNAECOLOGICAL OPERATIONS 



1^1 



To mark out the area to be denuded a Sims' speculum is inserted 
to retract the anterior vaginal wall ; and plugs of iodoform gauze are 
pushed into the rectum to prevent passage of faeces over the wound 
about to be made. 

The hooked forceps should seize the mucous membrane at the point 
c, which point should be in the median line of the recto-vaginal septum, 
and two cm. above the apex (a) of the tear through the sphincter. Two 
other points to be marked out are the extremities to which denudation 
is to take place on the inner surfaces of the labia majora ip b,). This 
butterfly-shaped area must now be bared of its mucous membrane by 
means of a knife or scissors ; there is no flap-splitting. 





c-^\ 



Fio. 164, 

A. Simon-Hegar method of suture, 2nd stage. The sutures 1 1,, 2 2., in the tongue c, have been tied 

1 1,, 5 5„ Vaginal sutures passed ; p, p,, p,, p,,. perineal sutures passed. 

B. Simon-Hegar method completed (side view), a, Vaginal sutures tied ; &, perineal ; c, rectal. 

Lateral venous sinuses may give rise to troublesome bleeding, but 
otherwise the haemorrhage requires no treatment. Hegar warns opera- 
tors against baring too extensive a surface, for when so much tissue is 
included between the stitches, suturing is rendered much more difiicult 
and union less likely to take place. 

The small central tongue should first be sutured and the stitches 
tied ; two or three are sufficient (Fig. 164, A, c). This is supposed to 
give additional solidity to the recto-vaginal septum. Next the sphincter 
should be repaired, the needle being passed as is indicated in Fig. 164, A, 
p^ Pi J. The knots of these sutures will lie in the anterior rectal wall. 
The vaginal and perineal stitches are next inserted in the usual way. 

The after treatment is as in the preceding operation, with the excep- 
tion that Hegar recommends a purgative to be given on the fifth day, 
and that as soon as two free actions have taken place no more aperients 
be administered. 

A. MaHui^s Metliod. — The denuded surface is the same as is recom- 
mended by Hegar and Simon, but the mode of suture is quite different. 
The flaps are brought together by the use of the continuous suture in 
superimposed layers (vide Figs. 169-171). The needle is entered at the 

3c 



754 



SYSTEM OF GYNECOLOGY 



apex of the central triangle (Fig. 163, c) and continued downwards, so 
as to unite the edges of the recto-vaginal septum and thus repair the 
sphincter ; an upward direction is now taken with the next superimposed 
layer, and finally the direction of the needle is again changed, and makes 
a series of superficial stitches from above downwards. Greater rapidity 
in the performance of the operation, and a closer adaptation of the raw 
surfaces, are the chief objects attained in this method. 

Alexander Duke^s Method. — This author published his mode of pro- 
cedure in the Duhliii Medical Press (9th May 1888) ; he considers it to 
be easy of performance and to make a good perineal floor. 

The patient being prepared in the usual way, anaesthetised, and 
placed in the dorsal decubitus, the left index finger is introduced for 
almost its entire length into the rectum. "A long, straight, double- 
edged bistoury is now made to pierce the tissues in front of the anus at 
right angles to the vulva, and, guided by the finger in the rectum, is made 
to penetrate the septum for two and a half inches " in an upward direc- 
tion. The incision may then be bilaterally widened 
to two inches as the knife is withdrawn (Fig. 165, k k^. 
The patient being placed in the left lateral posi- 
tion, and the points k k^ of the incision being pressed 
together, a lozenge-shaped opening will be made; 
sutures are passed in order to bring these raw sur- 
faces together. 

The sutures are introduced by means of a '' strong 
sickle-shaped needle " (with the eye near the point) 
mounted on a handle. For suture the author prefers 
silver wire to any other material. 

The needle is entered unthreaded at the edge of 
the incision on one side and, guided by a finger in 
the rectum, is made to travel under the raw surface 
to its full depth above, thus describing the arc of a 
circle; as the point of the needle appears directly 
opposite the wire is drawn through the eye : other 
sutures are passed in a similar manner. 

If, after tying the stitches, a finger of each hand 
be passed into the rectum and vagina respectively, 
the septum will be found much thicker, and the 
external tissue pushed fully an inch forward from 
the anus. 

Dr. Duke claims three great advantages for this 
method: (1) simplicity of performance and no fear 
of haemorrhage ; (2) no risk of sepsis, as the incision 
is not open for the admission of any discharge from 
either vagina or rectum during healing ; (3) no loss 
of tissue. 

Plastic Operations for Lacerations of the Pelvic floor Proper (class iii.). 
— The treatment to be adopted in these cases differs very materially 




'ks (2) 



^ a 




(3) 



# a 

Fig. 165. — Alexander 
Duke's method. (1) 
Transverse incision 
(k k,) made; (2) con- 
version of incision in- 
to a lozenge - shaped 
cavity ; (3) passage of 
sutures, a, anus ; cl, 
clitoris ; w, urethral 
orifice. 



PLASTIC GYNAECOLOGICAL OPERATIONS 



75: 



from the preceding : the objects to be attained are, first, to suture the 
torn ends of the levator to the lateral vaginal sulcus and perineum, 
and, secondly, to draw up or " lift " the pelvic floor. 

The patient, both as regards diet and antiseptic precautions, is pre- 
pared as in the former case ; and is placed in the dorsal decubitus. A 
Sims' speculum is inserted, and so placed as to elevate the anterior 
vaginal wall ; the lateral sulci and the posterior wall are thus exposed. 




Fra. 166. — Surface view of posterior vag-inal wall 
with right and left lateral sulci ; the anterior 
wall supposed to be removed : on left side 
(patient's) sutures inserted, right side as the 
sulcus appears untouched. 1 to 5 sutures ; 
their mode of passage being indicated by 
arrows ; h, hymeneal edge \tt , sites of attach- 
ment of tenacula : r, crest of rectocele. 




Fig. 16T. — Same view as Fig. 166 
with both lateral vaginal sulci 
sutured, 1, 2, 3, 4, 5. Quadri- 
lateral raw surface with sutures 
passed _25i, 'Pi- V%- At ?>5 but not 
tied ; r, crest of rtctocele ; u, 
anus ; h, t t,, as before. 

With the left forefinger in the rectum the space to be denuded is 
mapped out by means of the sharp-pointed scissors, as shown in Fig. 166, 
the base line of the double triangle being formed by the site of the 
hymen (h) : it is best marked out by inserting a tenaculum about three- 
quarters of an inch from the urethra on each side (tt^), and using slight 
tension. The tip of the tongue between the two triangles should be 
situated on the most prominent point or crest of the rectocele (Figs. 
166 and 167 r). The whole of the incisions must be contained in the 
vagina, and not extend to the vulva. The mucous membrane is now 
removed from this M-shaped space, particular care being taken to go 
deep enough into the sulci ; bleeding is rarely severe enough to require 
the application of ligatures. 

The insertion of the sutures is begun at the upper angle, usually on the 
left side (patient's) and after the manner shown in Fig. 166. The suture 
(1) is passed from the outside towards the median line ; not straight across. 



756 SYSTEM OF GYNECOLOGY 

but first downwards and inwards to the centre of the denuded surface, and 
then upwards and outwards towards the mucous membrane through the 
tongue of the flap, as shown by the arrows in the figure : a series of four 
or five of these sutures are passed in a similar manner. On inspection of 
Fig. 156, which is an imaginary transverse section parallel to one of these 
sutures, it will be seen that the torn ends of the levator are sutured to the 
relaxed sulcus, and on tying the knot complete restoration of the parts to 
their original integrity results. Having completed the left triangle the 
right is treated in the same way, and we find that a roughly quadrilat- 
eral raw surface is still left below (Fig. 167) ; this is united by passing 
and tying four or more transverse buried sutures as in the operation for 
incomplete perineal rupture : a Y-shaped cicatrix should be the result. 

The after treatment is exactly as detailed in class ii. ; the sutures 
usually remain buried, cause no irritation, and do not require removal. 

This is practically the operation devised by Emmet, and the steps of 
it are with very few exceptions the same as those laid down by him 
twenty-five years ago. 



B. OPERATIONS FOR DISPLACEMENTS OF THE PELVIC FLOOR 

Prolapsus uteri may be looked upon ''as a downward and outward 
displacement of the entire displaceable portion of the pelvic floor, past 
the entire fixed portion," with eversion of the walls of the vagina (Berry 
Hart). Simple prolapsus may be complicated by more or less procidentia 
of the anterior and posterior vaginal walls, and by a varying amount of 
hypertrophy of the cervix. Prolapse of the anterior vaginal wall may 
occur alone or carry the posterior bladder wall down with it (cystocele). 
Both conditions are frequently cured by the same operation (anterior 
colporrhaphy), although for the latter a special one has been devised 
(Stoltz). In a similar manner prolapse of the posterior wall may be 
simple ; or there may be in addition a displacement downwards of the 
anterior rectal wall (rectocele) : both of these are treated by elytro- or 
colpoperineorrhaphy. The operative treatment of cystocele, enterocele, 
urethrocele, and prolapse of the urethral mucous membrane will be con- 
sidered seriatim. 

Hypertrophy usually affects the body of the uterus (metritis) ; ap- 
parent cervical hypertrophy is the result of the prolapsus : a differential 
diagnosis must therefore be made from congenital hypertrophy of the 
vaginal and the supravaginal cervix. As prolapsus uteri is usually 
attended by retroversion of the fundus this latter condition may require 
treatment. 

For the purpose of selecting a suitable operation in each case it is 
better to divide these lesions into four divisions : — 

(a) Prolapsus uteri and procidentia vaginae (cystocele and rectocele, 
etc.), associated with cervical hypertrophy. (6) Prolapsus uteri and pro- 
cidentia vaginae, without cervical hypertrophy, (c) Prolapsus uteri, with 



PLASTIC GYNECOLOGICAL OPERATIONS 



757 



retroversion and procidentia vaginse. (d) Simple procidentia vaginae 
without uterine prolapse. 

The various plastic operations to which resort can be had for the 
relief of the above conditions are : — 

(i.) Those performed chiefly with the object of giving support to the 
prolapsed parts by repairing the perineum (perineorrhaphy) ; or, in addi- 
tion to this, suturing together the inner edges of the pared labia ma- 
jora (episio-perineorrhaphy). (ii.) Those performed with chief object 
of narrowing the vaginal walls (elytro- or colporrhaphy), or making a 
vaginal partition (Lefort's operation), (iii.) Combinations of i. and ii. 
(elytro- or colpoperineorrhaphy). (iv.) Those for prolapse of the pos- 
terior bladder wall with anterior vaginal wall (cystocele) of the urethra 
(urethrocele), of the urethral mucous membrane, and of the intestines 
(vaginal enterocele). (v.) Those tending to cure the metritis and cer- 
vical hypertrophy (curettage, cervical amputation), (vi.) Those for the 
relief of the retroversion (vaginal fixation or hysteropexy). 

(i.) Operations performed with the chief object of giving support to 
the prolapsed parts by perineorrhaphy or episio-perineorrhaphy. 

(a) Peri)ieorrliaphy or suture of the perineum has already been de- 
scribed (p. 747). Since the site of the operation scarcely includes the 
vaginal walls, it does not prevent their eversion ; although it may con- 
tract the vulvar outlet. It is a useless and inadequate procedure in any 
but the mildest cases, and simply enables a pessary to be retained. 

(/3) Episio-perineorrhaphy. This operation consists in paring the inner 
and lower borders of the external labia 
in addition to the perineal surfaces, and / 

suturing the opposing denuded areas to- 
gether. The same objection obtains here 
as in perineorrhaphy and, except for the 
purpose of supporting a pessary, it is 
found to be equally useless. 

(ii.) Operations performed with the 
object of narrowing the vaginal walls. 

(a) Elytrorrhaphy or Colp>orrhaphy. — 
Sims' method. This is only performed on 
the anterior vaginal wall (anterior colpor- 
rhaphy) ; as originally devised a V-shaped 
surface was denuded, with the apex point- 
ing downwards and commencing just above 
the urethra. On suturing these surfaces 
together a pocket was found to exist near 
the cervix into which the latter was liable 
to become incarcerated. Sims therefore 
added two short transverse denudations 
at the ends of this V (Fig. 168, a a,); on 
passing the sutures and tying them, a 



(S) 



af 




&■ 



■u 



Fig. 168.— Elj'trorrhaphy (Sims). The 
^ denudation is complete. aa,,Trans- 
^ verse bared surfaces ; 1, 2, 3, 4, 5, 
sutures passed ; c, cervix ; m, ure- 
thral orifice. 



complete vertical fold of the anterior vaginal wall is produced, which in 



758 



SYSTEM OF GYNECOLOGY 



suitable cases will be found to act as an adequate uterine support. Hegar 
makes his denuded surface in the form of a lozenge or rough ellipse, 
with the longer diameter in the axis of the vagina : he considers it use- 
less to endeavour to make the flap of any particular shape, and advises 
the excision of all the redundant anterior vaginal wall. For practical 
purposes the denuded surface may be considered as of a more or less 
oval shape (Fig. 169) ; its upper border reaches as near the cervix as 

possible according to the amount of mucous 
membrane which can be drawn down to the 
vulva, while its lower edge is four-fifths of 
an inch behind the urethral orifice. The 
cervix is drawn down and steadied with a 
silver wdre passed through its anterior lip. 
A Sims' speculum, lateral retractors, or the 
fingers of the assistant, may be used to ex- 
pose the site of operation. Having marked 
out the area to be denuded with a scalpel, 
the upper edge of the flap should be seized 
with hooked forceps, and the sides steadied 
by tenacula; the mucous membrane can now 
be separated from the underlying tissues 
by means of a knife or scissors and gentle 
traction : the edge of the knife should always 
be turned towards the flap, to avoid cutting 
too deeply. Bleeding is as a rule very 
slight ; if it persist, Spencer Wells' forceps 
should be applied and allowed to remain 
attached until the passage of the sutures. 

Closure of the wound may be carried 
out by means of a deep and superficial layer 
of interrupted sutures ; or by two or more 
layers of superimposed continuous sutures. 
The latter method is much the more expeditious, and will therefore be 
described. 

A small half or fully curved needle threaded with a long piece of 
fine carbolic silk, a needle holder, and a pair of hooked forceps will be 
required. 

The first suture is passed and tied (but not cut) near the urethral end 
of the incision (Fig. 169, a) ; the point of the needle is then entered at Z>, 
is passed beneath the denuded surface obliquely across to c, and then 
brought out, remaining exposed from c to d ; it is then again passed 
obliquely beneath the surface, in the direction of the arrows : as each loop 
is passed it is tightened, and the silk kept taut by an assistant, while 
another loop is being passed. In the figures these loops are shown as 
still remaining loose in order better to demonstrate their mode of inser- 
tion. On drawing the suture tight a longitudinal line is produced between 
the two opposed folds (Fig. 170, ^•A:,), and the denuded area will be diminished 




Fig. 169.— Anterior colporrhaphy ; de- 
nudation and first layer of con- 
tinuous suture completed, a to s, 
course of suture, the dotted por- 
tions being buried ; /, denuded 
surface ; ®, cervix ; t, tenaculum ; 
n, needle ; ■?;, vulval outlet ; cZ, 
clitoris; u, urethral orifice. 



PLASTIC GYNECOLOGICAL OPERATIONS 



759 



(Fig. 169), the 
The point of 




in size from side to side. The needle being brought out at . 

silk is kept tense, ready for the suturing of the next layer, 

the needle is passed superficially from a to 6 

(Fig. 170) over the longitudinal line (^), that 

is, from the operator's left to his right. It is 

then passed back again in an opposite and 

upward direction beneath the raw surface, 

and emerges at c; it is superficial again from 

c to d, and buried again from d to e ; the route 

taken by the needle being in the direction in- 
dicated by the arrows. The end of the suture 

is now brought out at s, and, if the denuded 

area be small, it may be tied and cut short. 

If, however, a third layer be necessary, the 

same procedure must be gone through, but 

from the urethral end downwards, the needle 

passing through points of junction of the 

denuded and mucous surfaces (Fig. 171). 

The needle has therefore during the opera- 
tion passed from urethra to cervix, from 

cervix to urethra, and back again to cervix. 

It is important to remember that the deeper 

layer must be transfixed by the loops of the 

more superficial layer during the course of 

the suture from side to side. 

The final cicatrix is obviously a straight line, running from the cervix 

to just above the urethra in the mid- 
dle of the anterior vaginal wall. 

The sutures do not require removal 
unless suppuration occurs along their 
track. 

(/3) Leforfs Operation. — This con- 
sists in the formation of an antero-pos- 
terior and longitudinal partition in the 
vagina. The originator of this opera- 
tion bases his practice on the fact that 
prolapse of the vaginal w^alls almost 
always precedes that of the uterus ; 
hence if the anterior and posterior vag- 
inal walls can be kept in apposition the 
uterus must necessarily remain in its 
normal situation. The patient is an- 
sesthetised and placed in the dorsal 

Fio. m.- Anterior colporrhaphy; passage of dcCubitUS. The utcrUS is draWU Out 

third and final layer of superimposed of the Vulva tO itS fullcst Cxtcut by 

suture. ^-, A',,, Site of second layer : 71 «,, p t „n„ Tj'^,,-^ i-,-.«ioi^-.-.i-. n-r./^ 

arrangement of silk preparatory to tying mCaUS of a VOlsclla. Four lUClSlOnS are 

knot to complete operation. made ou the autcrior vaginal surface, 



Fig. 170. — Anterior colporrhaphy; 
passage of second continuous 
superimposed suture, k k,. The 
longitudinal puckering produced 
by the first layer of suture. The 
other letters as in Fig. 169. 




760 



SYSTEM OF GYNJE,COLOGY 



Rt, 



enclosing a longitudinal space (Fig. 172, /) 6 centimetres long by 2 wide ; 
the upper transverse line should be as near the vulva as possible. This 

area is denuded in the usual manner. 
The cervix is now drawn upwards and 
forwards, and a similar area marked 
out and denuded on its posterior sur- 
face (Fig. 172, y;). Eeplacing the 
uterus sufficiently to bring the op- 
posed surfaces into contact, as in Fig. 
172, they are sutured together by a 
series of right and left lateral stitches 
(1 1,, 2 2J ; the first thread (1 IJ on 
the patient's left side being passed 
through the middle of the edge of the 
raw area nearest the cervix. The 
uterus is thus supported by a firm 
septum produced by the adhesion of 
portions of the anterior and posterior 
vaginal walls. The sutures are kept 
in for fourteen days or even longer. 
The operation is said by Lefort to allow of coitus, but it is obviously one 
which would be selected for patients of more advanced age, and who 
have ceased to menstruate. Its performance has been attended by much 
success in France, but hitherto it has not gained favour elsewhere, 
(iii.) Combination of i. and ii. (Elytro- or Colpoperineorrhaphy). 




Fig, 172. — Lefort's operation; the anterior and 
posterior longitudinal areas //, denuded. 
Two sutures, 1 1,, 2 2,, passed on left side, 
one on right ; cl, clitoris ; u, urethral ori- 
fice ; cy, cystocele; /*, rectocele; a, anus. 




Fig. 1T3. 



-Colpoperineorrhaphy (A. Martin). 1st stage, 
passed (a,) and tied (a). 



Surface denuded, sutures 



This operation consists in the performance of a posterior colporrhaphy 
concluded by an additional perineorrhaphy. The methods advocated 
by A. Martin and Hegar are those most in vogue ; the former has been 
selected from among a large number for description. The advantage 
obtained by it is the preservation of the posterior column of the vagina, 



PLASTIC GYNECOLOGICAL OPERATIONS 



761 




Fig. 174. — 2nd stage. 
First layer of superim- 
posed suture passed. 



which is very resistant and, according to Freiind, should always be 
maintained intact. 

A. Martinis Operation. — The usual antiseptic precautions must be 
taken in this as in all plastic operations ; the patient being ansesthetised 
and in the dorsal position, the posterior wall of the vaginal cul-de-sac is 
seized by two pairs of hooked forceps, one on each side 
of the median line. Some traction is put upon them, 
with the result that the vaginal column appears 
strongly marked. On each side of this are made two 
longitudinal incisions ; two corresponding flaps are 
removed, the amount varying according to the redun- 
dancy of the vaginal walls (Fig. 173, a a^. The con- 
tinuous buried suture is applied to each and two linear 
cicatrices result (Fig. 174). This concludes the first 
part of the operation or the posterior colporrhaphy ; 
the perineorrhaphy or perineauxesis has now to be 
performed. The boundary lines are almost the same 
as in the operation for incomplete perineal rupture, 
the contained space presenting a semilunar appear- 
ance while the parts are at rest ; but when traction is 
made upon its lower or anal extremity it assumes a 
lozenge shape (Fig. 174). The deep and superficial 
superimposed buried suture is now passed after the manner already 
described (p. 758), and the operation is finished ; a Y-shaped scar results 
(Fig. 175). If antiseptic precautions have been carefully carried out, 
no suppuration takes place along the track of the sutures, 
and these may be left untouched. 

(iv.) Operations for Cystocele, Urethrocele, Prolapse 
of the Urethral Mucous Membrane, and Enterocele. 

(a) Cystocele. — Whether the prolapsed anterior 
vaginal wall carry down the posterior bladder wall or 
not the operative treatment is the same; namely, by 
anterior colporrhaphy, already described (p. 757), or by 
a special method devised by Stoltz of Nancy. 

The instruments necessary are a No. 8 male bladder 
sound, two tenacula, hooked forceps, sharp-pointed angu- 
lar scissors, half-curved needles, and a holder (Spencer 
Wells' or Hagedorn's according to the kind of needle 
used). Fine carbolised silk is preferable for the suture. 
The parts are best exposed by means of a Sims' specu- 
Superficiai layer luui aud a silvcr wlrc passcd through the cervix (x), by 
sutur^^pa'^ssS • ^^^^ns of which traction downwards and backwards may 
operation com- bc cxcrtcd. Four poiuts must be selected : two lateral 
piete. ^j,.^^ 176, 1 1^), fixing the external boundaries of the sur- 

face to be bared, one behind the urethral orifice (2), and another in front 
of the cervix (3) : these four points should be capable of fairly close 
approximation. They are united by curved incisions, so that the space to 




Fig. 175. — 3rd stajre. 



762 



SYSTEM OF GYNECOLOGY 




^ /• 


-—1, 


rffc^ 




py- 


m a 





be denuded is almost circular in shape (/). The sound is now passed 
into the bladder, and the mucous membrane of the vagina kept on the 
stretch by pressure of its point. Denudation 
should be performed in the usual way with knife 
or scissors, the sound being used as a guide and 
a resistant body. As a rule no bleeding requires 
attention. The needle being threaded, its point 
is inserted on the right (operator's) side of the 
urethral orifice, and slightly below it. It passes 
beneath the mucous, and appears upon the raw 
surface ; is again introduced on the mucous, and 
again made to come out on the denuded surface. 
This manoeuvre is repeated all round the edge 
of the wound, and finally the thread brought out 
on the left (operator's) side of the urethra and 
below it (Fig. 176). Traction is then made upon 
the two ends of the suture at the same time 
that the sound (now removed from the bladder) 
is used to push in the projecting cystocele. The 
ment for tenacuia before edgcs of the dcuudcd surfaco are by this means 

denudation; cZ, clitoris : u, -, . .-, t.t t tiitt n 

urethral oniice;», cervix, ^, orawu together and the prolapscd bladder wall 

wire or tenaculum; a, anus, rcstorcd to its uomial situatiou. Ou tying the 

ends of the silk suture, the site of the operation will be marked by a 

pouch-like cicatrix. The urine should be drawn off every six or eight 

hours, and the suture withdrawn about the tenth day. 

This method is of great value when combined with Martin's or Hegar's 
colpoperineorrhaphy for the treatment of cystocele and rectocele. It 
results in a very firm circular cicatrix, and requires very little manual 



Fig. 176.— Stoltz's operation for 
cystocele. /, Denuded area ; 
1 1,, 2 3, points of attach- 



d 



dexterity for its performance. 

The objection to Stoltz's method is that 
his operation tends to draw the cervix 
downwards ; hence with a uterus pro- 
lapsed in a state of ante-version it would 
tend to aggravate the condition. 

(/5) In urethrocele there is a localised 
dilatation of the urethra in its middle 
third, the neck of the sac being more or 
less constricted. A certain amount of 
urine collects in this sac, and becomes 
alkaline or putrid (Fig. 177). 

The sac should be opened by means 
of the scissors, or Pacquelin's cautery, and 
allowed to drain until the parts are in a 
more healthy condition : a very simple plastic operation can then be 
carried out, the edges of the wound being denuded and brought together 
by a deep and superficial set of interrupted sutures. 

(y) Prolapse of the urethral mucous membrane is recognised by the 




1 



Fig. 177. — Urethrocele ; lateral view in 
section, a, Vaginal surface of sac ; 
&, urethra ; c, cavity of urethro- 
cele ; d, bladder ; e, anterior wall 
of urethra ; /, posterior wall. 



PLASTIC GYNECOLOGICAL OPERATIONS 763 

appearance at the meatus of a swelling of deep red colour, easily 
reducible. 

Emmet's operation for the cure of this displacement is as follows : 
The patient is placed in the left lateral position, and a Sims' specnlum 
inserted into the vagina ; a button-hole longitudinal slit one and a half 
inches long is made into the urethra, and through this orifice from 
before backwards the redundant prolapsed portion of mucous membrane 
is drawn with a tenaculum. This is held by an assistant in the wound 
while a large-sized metal bladder sound is passed into the urethra, so as 
to smooth out the lining membrane and push it towards the neck of the 
bladder. 

Sutures should now be passed through the flaps of the wound 
transversely, and in such a manner as to transfix the drawn-through 
lining membrane ; the excess of this tissue is now cut away, and the 
opening brought together by means of interrupted carbolic silk sutures. 

(8) Vaginal enterocele may be either anterior or posterior ; the anterior 
is so rare that it may be neglected. In posterior vaginal enterocele the 
intestines are forced down between the anterior rectal and posterior 
vaginal walls : as a consequence a large mass is found projecting like a 
rectocele. The cervix and uterus, however, remain in their normal 
situation. The patient being anaesthetised, and in the dorsal position, a 
volsella is attached to the posterior lip of the cervix, and some traction 
downwards and forwards is used ; a space is then denuded on its pos- 
terior surface, and a corresponding one on the posterior vaginal wall ; 
these raw surfaces are then sutured by means of carbolic silk in the 
usual manner, after reduction of the intestine. 

(v.) Amputation of the cervix may be necessary for either supra- 
vaginal or infravaginal hypertrophy. 

Supravaginal hypertrophy of the cervix is essentially a hypertrophy 
of the cervix above its insertion into the vagina ; it occurs, as a rule, in 
nulliparous women. The uterus is increased in weight which causes pro- 
lapse ; it should be noted that in this variety, as the uterus descends, 
prolapse of the upper part of the vagina takes place first, whereas in pro- 
lapsus uteri of the multiparous woman, rectocele and cystocele appear 
and precede the uterine prolapse. 

Infravaginal hypertrophy — or more properly " elongation " — may occur : 

1. As a complication of prolapsus uteri, when indeed it is apparent 
only : reduction of the displacement usually results in a disappearance 
of the hypertrophy. 

2. As a congenital condition. 

Amputation of an apparently elongated cervix in prolapsus uteri is 
rarely justifiable, but in the congenital form a plastic operation is cer- 
tainly indicated (vide p. 769). 

(vi.) Vaginal fixation (Hysteropexy) consists in fixing the retro- 
verted fundus in a forward or anteverted position by suturing it to the 
anterior vaginal cul-de-sac. 

This operation, which was originated by Shucking, has been im- 




764 SYSTEM OF GYNECOLOGY 

proved by Dtihrssen, and modified in some of its minor details by 
Mackenrodt. 

Dilhrssen^s Operation. — The patient being under the influence of an 
anaesthetic is placed in the dorsal position, with knees supported and 
kept apart by a Clover's crutch. The genitalia are thoroughly cleansed 
with 1 in 1000 mercurial solution, and, after inserting a Sims' speculum, 
the vaginal mucous membrane is carefully rubbed over with cotton wool 
dipped in the same mixture. 

The anterior lip of the cervix is now seized with a volsella, and the 
uterus dragged down as low as possible ; the uterine cavity is slightly 
dilated, and then scraped with a sharp flushing curette : possible con- 
tamination of the uterine sutures to be passed later is thus avoided. If 
the cervix be much hypertrophied it is amputated, as a large cervix 
tends to prevent the uterus remaining in a position of anteversion. 

^ A superficial transverse incision is 

'\,,g made with a scalpel at the insertion of 

the anterior vaginal wall into the cervix ; 

^°^^ ' *'"'^' ^ with scissors and the forefinger, the 

^ S,^s/ ,' \ X£^^„„„.-^ cellulartissue(Fig. 178, dcy between the 

a — -i^^^mt ^^^PJ:™—-- ^/ bladder and cervix is broken down until 

'•1 ^i^^-u^^^ the peritoneum lining the utero-vesical 

pouch is reached. The peritoneal cavity 
/ is now opened and the edges sewn to 

Fig. 1T8. - Vaginal fixation ; transverse and thoSC of the Vaginal WOUud. 

somewiiat oblique section above the * -x-r o -i i i_i i_ 

level of the internal os uteri. 1 1„ A No. 8 SllvCr male Cathctcr IS UOW 

Temporary uterine suture ; 2 2 suture passed iuto the utcrUS, and bv mcaUS of 

Including vaginal flaps, art,, and uterine fl . •, • , , i 

wall ; this is tied at x ; &, anterior the usual tour-cle-maitre it IS antevertecl ; 
vaginal cii^-c^e-sac/dc?,, cellular tissue by p^gssure backwards of the handle 

m front of uterus ; c, catheter m e, J r 

uterine cavity; u, uterine body; /, the funduS, COVCred by the pcritoueum, 

^^^^^®''- appears at the incision wound. With 

a handled needle provided with a rectangular curve, a stout carbolised 
silk suture or silkworm gut stitch is passed through the anterior wall 
of the uterine fundus as high up as possible, the vaginal flaps not being, 
however, included ; the ends of the suture are given to an assistant, 
who exerts traction downwards, allowing of the introduction of two or 
more further sutures into the anterior wall higher up than the first ; the 
last should pierce the uterus at the level of the catheter point (Fig. 178, 
1 1^). These are temporary, for traction only. 

Three sutures should now be passed one above the other through the 
uterine wall, but including the edges of the vaginal flaps (2 2^). The 
temporary ligatures may now be removed and the permanent ones tied ; 
a superficial continuous suture may be inserted to obtain an accurate 
adaptation of the flaps. 

The uterus will now be felt in a state of anteversion. After washing 
out the uterine cavity with an antiseptic solution the vagina must be 
packed with iodoform gauze. 

The patient should be kept at absolute rest for fourteen days, and 



PLASTIC GYNECOLOGICAL OPERATIOXS 765 

have a ring pessary inserted before getting up. The value of this 
proceeding is still uncertain. The three dangers of the operation are — 
(i.) cutting one or both ureters 5 (ii.) wounding the bladder ; (iii.) haemor- 
rhage from the vaginal flaps. Two after-effects must be taken into con- 
sideration ; namely, a certain irritability of the bladder and a tendency 
to miscarriage, owing to the fixation of the anterior uterine wall to the 
vagina. It has been denied, however, by many that either of these 
sequels are met with. Diihrssen has recently published statistics of 
197 cases with one death (about 0*5 per cent). 

MackenrocW s Modification. — This operator does not consider it neces- 
sary to open the peritoneum in the anterior cul-de-sac, and is strongly 
opposed to fixing the uterus by carbolic silk suture or silkworm gut 
stitch ; he transfixes the body of the uterus in preference to the fundus 
only, and also prefers a longitudinal vaginal incision. 

The advantages claimed for this method are — 1. That the longitudi- 
nal incision does away with the risk of injury to ureters or bladder, and 
again that, where the vagina is roomy, and the walls lax, this incision 
can be converted into a rhomboidal one ; thus an anterior colporrhaphy 
can be carried out, which strengthens the point of attachment of the 
uterus. 2. That by using absorbent catgut the uterus is maintained in 
place purely by adhesions, which in the event of pregnancy ensuing are 
capable of being stretched ; repeated miscarriage after this operation is 
thereby avoided (Webb). 



C. OPERATIONS FOR LACERATIONS OF THE CERVIX (XOT RECENT) THE RE- 
SULT OF PARTURITION (eMMET's OPERATION OR TRACHELORRHAPHY 
AND ITS modifications) 

If the cervix of a woman who has been confined at least two months 
be exposed by means of a Sims' speculum, one or more of the following 
conditions may be observed : — 

(a) The cervix may be normal, with the exception of two lateral 
notches more or less marked. 

(/5) The anterior and posterior lip may be separated by one or two 
lateral rents extending to the vaginal roof. 

(y) One or two lateral lacerations may be present as before, but in 
addition considerable extroversion of the cervical mucous mem- 
brane ; the uterus will be probably subinvoluted, and the patient 
suffering from menorrhagia, leucorrhoea, backache, and reflex 
disturbances. If a tenaculum be applied to the outer surface 
of each lip, and the two approximated, the extroversion dis- 
appears, and the rent becomes more apparent. 

(8) The anterior lip may be torn through from front to back, the 
posterior being intact ; or the reverse obtains, the posterior lip 
only being injured. Extroversion may or may not complicate 
either of these injuries. 



766 SYSTEM OF GYNAECOLOGY 

(e) The lacerations may be arranged in a stellate form and of varying 
depth. 

Of these varieties none but those included under the headings (y) and 
(S) require operation, and then only when extroversion is present. Until 
recently it was considered that there was a direct relation between cer- 
vical lacerations and cancer ; but so far no affirmative evidence has been 
adduced in support of this surmise. It is therefore obvious that the 
necessity for the performance of this operation does not frequently 
arise. 

Operation when there is a simple deep bilateral laceration with 
extroversion. 

Preliminary Treatment, — Vaginal injections of hot water (110° F.) 
should be used night and morning for a month or six weeks before the 




Fig. 179. — Emmet's scissors (left angular). 



operation, and during this time the patient should be in the recumbent 
position. By their means local congestion is relieved, and the loss of 
blood at the operation from the denuded surfaces is much less. Should 
there be any cicatricial tissue at the base of the broad ligament in con- 
nection with either laceration, the corresponding fornix should be painted 
once every seven days with strong lin. iodi. The temperature should 
be normal night and morning, the urine free from albumin and sugar, 
and the general health of the patient good; it must be ascertained that 
there is no possibility of existing pregnancy. 

Actual Operation. — The instruments required are : A Sims' specu- 
lum; volsellas and tenaculums; long-handled angular bladed knives 
(right and left) ; Emmet's scissors (right and left), angular (Fig. 179) 
and angular and curved (Fig. 180) ; needle holder ; short stout needles, 
with sharp triangular points, straight or very slightly curved ; two sizes 
of silver wire; carbolised silk suture (medium thickness). 

If necessary the operation, which is painless, may be performed 
without general anaesthesia, local injections of a cocaine solution into 
the cervix being all that is requisite. 

If a general anaesthetic be preferred, the patient, being brought under 
its influence and an antiseptic vaginal douche given, should be placed in 
the semiprone (Sims') position. The necessary manipulations are carried 
out much more easily in this attitude, although respiratory effort is some- 
what interfered with. Some operators prefer the dorsal decubitus as 
giving more space, but this is open to doubt. 



PLASTIC GYNAECOLOGICAL OPERATIONS 



767 



As subinvolution is almost invariably present, it is considered advisa- 
ble to commence the procedure by slight cervical dilatation and curettage ; 
it takes but a few more minutes, and is of great benefit to the patient. 




Fig. 180. — Emmet's scissors (an^lar and curved). 



Having performed this with a flushing curette, introduce the Sims' 
speculum (Fig. 181, S) and expose the cervix. A piece of stout silver 
wire (^t'^) should be passed deeply through the anterior lip (aj. By means 
of this steady traction can be 
made downwards, and the 
uterus kept firm while denuda- 
tion and suturing are carried 
out. 

If there be marked extro- 
version, with hypertrophy of 
the cervical glands, and the 
parts bleed easily on handling, 
erasion by means of the curette 
will make the subsequent steps 
easier of performance. 

Having passed the uterine 
sound to mark the site of the 
internal os uteri (o u i), denuda- 
tion is commenced. The lower 
portions of the anterior and 
posterior lips are first pared 
by means of the angular knives 
and scissors. An important 
site which frequently escapes is the deep angle of the laceration on each 
side (I /J. The upper portions of the anterior and posterior lips may 
now be treated in a similar manner. A sufficiently broad strip (a a J must 
be left unpared on both lips to avoid complete closure of the cervical 
canal when suturing is carried out. Any cicatrices at or about the angles 
of the laceration should now be excised ; but, in doing so, large vessels 
may be opened and serious haemorrhage result. Frequently the tissue 
is extremely hard, and great patience is necessary in order to denude 




Fig. 181.— a 
lip; a a 



anterior cervical 
stout wire by which 



Posterior cer\'ical lip ; 

undenuded strip ; u\ 
cervix is steadied ; S, Sims' speculum (blade in sec- 
tion); 1 1,, angles of deep laceration ; o u i, os uteri 
internum ; n, needle passing through upper bared 
surface ; s,, double thread, through loop of which the 
wire suture w is passed ; 1 1,, 2 2,. sutures inserted 
but not tied. 



768 SYSTEM OF GYNECOLOGY 

the flaps thoroughly. An intermittent antiseptic douche should be used 
during denudation to wash away the blood and to preserve asepsis. 

The Introduction of the Sutures. — Silvered copper wire of medium 
stoutness, and about 12 inches in length, should be used for each suture. 
The short, stout triangular pointed needle (n) is first doubly threaded with 
carbolised silk {s^, so that a loop of 3 or 4 inches in length is produced. 
The needle and silk suture are passed, as in the upper portion of the figure, 
on the lower bared surface in the direction of the arrow, the loop remain- 
ing suspended from the point of entry. The wire suture {w) is hooked 
through it, and the needle and silk are rapidly pulled through beneath 
the raw surface, drawing the wire in their track. The needle is entered 
again at the edge of the undenuded strip, and passed directly outwards, 
the same manoeuvre with regard to the silver wire being carried out. 
The other sutures are passed in a similar way ; generally three or four 
are sufficient. The upper bared surface is treated in a like manner. 
The stout wire (lo^) is now removed, and the anterior and posterior flaps 
(a^ a) are brought into apposition. The wires are twisted, but not too 
tightly ; and the sound is passed to test the patency of the cervical canal. 
The ends of the wire sutures may be cut short or twisted together, 
covered with protective gauze and allowed to remain in the vagina. 
The latter method permits much easier access to the stitches when their 
removal is required. 

The after treatment is not different f I'om that to be followed after 
any other plastic operation. Vaginal gauze packing is not necessary. 
Should secondary haemorrhage occur the cervix must be exposed through 
a Sims' speculum, and a suture passed through that half from which the 
bleeding is taking place. On tightly tying this the haemorrhage will 
cease. The sutures may be removed on the tenth day, a small blunt 
hook being required to bring the loop of wire under the action of 
the scissors. In a successful case the cervix assumed a virgin appear- 
ance. 

Dlihrssen describes a modification of Emmet's operation by " flap- 
splitting." He considers that a cervical laceration may be repaired with- 
out denudation by cutting into the tear at the line of junction of the 
cervical mucous membrane and that of the portia, the incision being -J- cm. 
in depth. On putting traction on the wound edges a raw surface is 
produced, the upper half of which is to be sutured to the lower. Another 
advantage claimed is that the cicatricial bands extending from the lacera- 
tion into the parametric tissue can be safely divided. 

Should the tear of the cervix have extended into the parametric 
tissue a cicatrix results, which draws over the uterus to the affected side. 
Severe pain may be caused by this condition, and Martin has proposed 
and carried out a plastic operation for its relief. The patient being 
anaesthetised, and in either the dorsal or left lateral position, the uterus 
is pulled over from the affected side, and a semilunar antero-posterior 
incision made over the base of the broad ligament, following the line of 
the cervix. The anterior and posterior extremities of the wound are 



PLASTIC GYNECOLOGICAL OPERATIONS 769 

brought together by sutures, so that a transverse cicatrix results. 
Martin reports excellent results from this method. 



D. OPERATIONS FOR CERTAIN CERVICAL DEFORMITIES AND INFLAMMATIONS 

Cervical deformities requiring operation include stenosis of the os 
uteri externum and inf ravaginal hypertrophy ; in chronic and intractable 
inflammation of the mucous membrane of the cervical canal resort to the 
knife is sometimes also necessary. 

1. For stenosis of the os uteri externum, when associated with a coni- 
cal cervix, Marckwald has introduced a flap operation which will be 
described in the next paragraph. In Germany and America it has met 
with considerable favour, but in England simple bilateral incision has 
been deemed sufficient. 

2. In hypertropliy of the vaginal portion there is no thickening of the 
mucous and underlying tissues, hence the diameter of the cervix is not 
increased. On examination, the anterior and posterior fornices are in 
their normal situation, and the fundus uteri is found at its proper level 
in the pelvis ; the sound may pass from 4 to 6 inches into the canal of 
the cervix. The os uteri externum is frequently very small. For the 
treatment of this condition nothing avails but removal of the hyper- 
trophied portion ; many methods have been recommended for this pur- 
pose, of which three have been selected for description. 

(i.) Conoidal excision (Sims). 

(ii.) Circular amputation (Hegar). 

(iii.) Wedge-shaped excision of each lip (Marckwald). 

A modification of ii. and iii. is advocated by A. R. Simpson. 

Sims excised a cone-shaped portion of the cervix, and sutured the 
vaginal and cervical mucous membranes together. 

Hegar has fully described his technique in his work. The patient 
being anaesthetised and in the dorsal position, the cervix is pulled down 
by a volsella and amputated with knife or scissors, the cut being directly 
transverse to the long axis of the hypertrophied organ ; a certain amount 
of shrinkage of the stump takes place, producing an inversion of the 
vaginal mucous membrane (Fig. 182 A, a). A raw surface remains, over 
which the vaginal and cervical mucous membrane must be united by sut- 
ures. These are passed in the following manner : a short straight needle, 
double-threaded with a loop of carbolised silk, is passed from the vaginal 
mucous membrane (beneath the raw surface of the stump) to that of the 
cervix (c) in the direction of the arrows, and then brought back over the 
surface (Fig. 182 A, 1 1^). Into this loop is hooked a piece of silver wire 
about 10 inches long, and by means of the silk pulled through the stump, 
which thus takes the place of the original suture : a series of these are 
passed and arranged in a radiating manner (1 1^, 2 2^, 3 3,), and the wire 
loops are twisted so as to secure accurate adaptation and union by first 
intention (Fig. 182 B). The patient should remain in bed for fourteen 
days, and the satures are best removed on the tenth day. 

3d 



770 



SYSTEM OF GYNECOLOGY 



MarckwaWs method, wliich. is a modification of Simon's, has been in 
general use in Germany since the publication of his original paper on the 



w 



(B) 




Fia. 182. — Amputation of cervix (Hegar). (A) Mode of passage of sutures ; a, inverted vaginal mucous 
membrane ; b, cervix ; c, cervical canal in section ; d, raw^ surface of stump. (B) Sutures tied ; 
letters and figures as in A. 

subject. The cervix is split into an anterior and posterior lip by means 
of scissors or the knife (Fig. 183 A, a b), and out of each is excised a 
wedge-shaped piece leaving a deep groove (Fig. 183, A, c c c^ c^ B, c c^), 
bounded by an anterior (B, d d^ and posterior (B, e e^ flap, front and 



Anterior 



.d 




Atiteriof 



Fig. 183. — Amputation of the cervix (Marckwald's method"). (A) Surface view, a b. Incision dividing 
cervix into anterior and posterior lips, in each of which is a wedge-shaped groove, c c, c, c,. The 
direction and mode of passage of two sutures is shown. (B) Side view. The dotted outline indi- 
cates the original dimensions of the cervix h h,ff\ anterior and posterior fornix ; d e, d, e,, anterior 
and posterior flaps of anterior and posterior lips of cervix respectively ; c c,, as in A. 

back ; the cervical surface of each is united to the corresponding vaginal 
surface by a series of sutures which are passed as shown in the diagram. 
The sound should be passed to ascertain if the cavities of cervix and 
body together do not exceed 2^ to 3 inches. 



PLASTIC GYNECOLOGICAL OPERATIONS 771 

The advantages of this operation appear to be that it is almost 
entirely free from danger ; no after bleeding can take place and, as a 
patent external os uteri is produced, it is of much value in stenosis ; 
lastly, the technique is very simple and convalescence is rapid. 

Simpson of Edinburgh introduces the sutures before amputating the 
hypertrophied cervix, the needle being passed through the whole thick- 
ness of the organ. After removing the mass each stitch is cut in two at 
the site of the cervical canal, and the stump treated as in Hegar's method. 
There are manifest advantages in this method: "It is easier to pass the 
needle through the dense tissue when the cervix is fixed Avith the vol- 
sella ; the sutures serve as a means of traction when the portion grasped 
by the volsella has been cut away." Ligatures can be tied immediately 
the flaps have been made by amputation (Hart and Barbour). 

If the sutures are of silver wire they should be removed in about ten 
days' time by means of a Sims' speculum, a rake (a blunt bent probe) to 
bring the embedded sutures into view, and a pair of scissors. 

The removal of a hypertrophied cervix by an ecraseur or gal van o- 
caustic wire is not to be recommended. 

3. In certain cases of intractable cervical catarrh, it is a legitimate 
proceeding to excise the mucous membrane lining the cervix. 

Schroeder's method consists in drawing down the cervix by means 
of two tenacula, one being attached to each lip; it is then divided 
bilaterally with knife or scissors, the incision being carried up to the 
vaginal fornix. A transverse incision is made at the base of each lip, 
and as high as can be reached, cutting right through the mucous mem- 
brane [_vide Figs. 46, 47, p. 202, in Dr. Barbour's paper, " Inflammation 
of the Uterus "]. The point of the knife is next entered at c, and the 
blade passed up to join the deeper part of incision a. A large piece of 
mucous membrane is thus excised ; the same manoeuvre is carried out 
on the other side. The points a and c are brought together by sutures. 
The lower and middle portions of the cervical canal are now lined by 
vaginal mucous membrane. 

Martin combines this with amputation of the cervix in his method 
of treating these cases. 



K. OPERATIONS FOR REPAIR OF FISTULOUS OPENINGS BETWEEN THE 
BLADDER OR INTESTINE OR OTHER VISCERA 

It will be convenient to subdivide fistulas into those in which the 
chief symptom is an involuntary escape of urine through the vagina 
(urinary) and those in which intestinal contents are similarly passed 
(faecal). 

Urinary Fistulas. — The septum between the genital and urinary 
channels may have its continuity destroyed in various situations ; any 
artificial communication thus produced between two organs is called a 
fistula. The varieties of urinarv fistulas are six in number, and are 



772 SYSTEM OF GYNECOLOGY 

named according to the organs between which an artificial opening 
occurs : 1. Urethro- vaginal ; 2. Vesico-vaginal ; 3. Vesico-utero-vaginal 
(juxta-cervical) ; 4. Vesico-uterine, cervical, corporeal ; 5. Uretero-vagi- 
nal; 6. Uretero-uterine. 

A rare condition in which the intestine (small or large) opens into 
the bladder, and faeces are passed with the urine, constitutes an entero- 
vesical fistula. 

Of urinary fistulas, by far the most frequent is the vesico-vaginal ; 
it is due either to direct injury to the vesico-vaginal wall during labour, 
or to a sloughing of the same subsequently, owing to prolonged impaction 
of the foetal head. An ulcerated opening may result from a vesical cal- 
culus. This variety of fistula frequently complicates the extension of 
malignant disease from the uterus to the bladder wall, and is artificially 
produced as a means of cure for chronic cystitis (Emmet's operation). 

The urine dribbles away involuntarily, in a more or less continual 
stream ; and the passage of the catheter gives a negative result. An 
exception, however, is found in those cases in which the opening exists 
above the orifices of the ureters ; the patient then has a more or less 
considerable retentive power when in the erect position. Incontinence 
occurs immediately after labour, when the accident is due to the forceps 
or version ; if it be not noticed until a few days subsequently it is due 
to sloughing of the parts pressed upon. 

In urethro-vaginal fistula the urine is retained in the bladder, but 
passed in a stream through the lower portion of the vagina. In uretero- 
genital fistula urine is voided voluntarily at the usual times, and if the 
catheter be passed into the bladder a certain amount of secretion (but 
not so much as usual) is drawn off ; the vagina will at the same time be 
found moistened with urine. This accident may be a sequel of total 
extirpation of the uterus. It will be most convenient to describe (I.) the 
operative treatment of vesico-vaginal fistula ; and next (II.) the more 
complicated varieties. 

I. Vesico-vaginal Fistula. — As this lesion is most frequently the re- 
sult of prolonged pressure during parturition its situation will necessarily 
depend upon the point at which this pressure was most strongly exerted ; 
hence it is usually found in the median line and behind the symphysis 
pubis. If, however, at the time of labour the bladder were distended, 
and therefore above the symphysis, the solution of continuity will be 
above the ureteral orifices. The size of these openings varies very much : 
the whole vesico-vaginal septum may be destroyed, producing an aperture 
as large as the palm of the hand ; or the orifice may be so small as to 
escape notice, and admit a bristle only. The usual shape is oval or 
elliptical ; but should cicatricial bands in the vaginal wall be present, 
the edges of the aperture may present every variety of irregularity. In 
the larger kinds the anterior bladder wall is protruded through the 
opening and may be covered with incrustations. The continual flow of 
alkaline and often decomposing urine over the vaginal walls and external 
genitals produces much redness, soreness, and swelling of the parts ; 



PLASTIC GYNECOLOGICAL OPERATIONS 773 

urinary concretions may be formed along the edges of the fistula or 
in the vagina. A urinous and characteristic odour emanates from the 
patient's person. There is usually amenorrhoea. 

The plastic means adopted for the cure of this condition are by : — 

(A.) The interrupted suture directly applied to the fistulous opening. 
(B.) Elytroplasty. (C.) Occlusion of the vagina below the fistula (kolpo- 
kleisis). 

(A.) Suture. — Three operators have each introduced a method of 
denuding and suturing a fistulous opening to Avhich their names are 
respectively given ; they are Sims, Simon, and Bozeman. 

(i.) Sims' Method. — This is chiefly characterised by the careful pre- 
paratory treatment of the patient before operation, and by the use of 
silver wire for sutures ; it is much in vogue in England and America. 
A description of this procedure may be given under four headings : — 

(a) Preparation of the patient. {(S) Denudation or vivifying of the 
edges of the fistula, (y) Passing and securing the sutures. (S) After 
treatment. 

(a) Preparation of the Patient. — The importance of this measure can- 
not be over-estimated ; without it failure will occur almost inevitably. 
Six months or more after the labour is the earliest time at which opera- 
tive measures should be adopted. Constitutional treatment by means of 
tonics, a stay at the sea-side, with a course of shampooing and careful 
dieting, must be carried out for a month or six weeks. Hegar and 
Kaltenbach think six to eight weeks after the labour is the best time 
for operation. Much care and patience are necessary in the local manage- 
ment of such a case. The chief object to be attained is a healthy con- 
dition of the edges of the fistula, which are frequently inflamed, thickened, 
and covered by urinary deposits, usually phosphatic in nature. These 
deposits should first of all be removed by means of a soft sponge, and the 
raw surface brushed over with a weak solution of silver nitrate. Prequent 
hot vaginal douches and hip baths should be administered, and the parts 
carefully dried afterwards. The vaginal mucous membrane and vulva 
are then best smeared freely with vaseline to protect them from the 
action of the irritating urine. The napkins used by the patient must 
be thoroughly washed free of the urine with which they are saturated, 
and not simply dried. 

So long as the phosphatic condition of the urine is present no local 
improvement will take place, hence it is desirable to produce acidity, 
and the following prescription is best adapted for that purpose : Acid, 
benzoici 3j., Acid, borici 3iss-5ij., Aq. 5vj. ; yV^h part in water three 
times daily. 

When a state of acidity is attained the dose may be reduced to such 
a quantity as to just keep the urine acid; too long a continuance of the 
larger dose is apt to produce gastric disturbance. 

Vaginal cicatrices, besides the pain to which they give rise, often ob- 
struct the view and treatment of the fistula, the introduction of sutures 
being rendered impossible thereby. These should be severed by scissors 



774 



SYSTEM OF GYNECOLOGY 



in preference to the knife, as the haemorrhage is less. A Sims' glass 
vaginal tube is then passed into the vagina to prevent reunion of the 
raw surfaces, and it may be worn a few hours daily ; when it is removed 
the douche is to be given. Pressure applied in this manner frequently 
results in an absorption of the cicatricial tissue. 

For the operation an anaesthetist, three assistants, and a nurse are 
requisite ; one nurse will hold the Sims' speculum and elevate the right 
buttock, another will sponge and hand the instruments. The use of 
chloroform is advantageous in that it permits free access to the parts ; 
the actual pain of the operation itself, however, is trifling. 

The following instruments are necessary : A Sims' speculum ; two 
flat spatulas ; three long-handled knives, one with a long haft and a 
short, straight, narrow blade, the other two with angular blades (right and 




Fig. 184. — Vesico-vaginal fistula knives (Sims'). 



left) (Fig. 184) ; two long-handled, sharp-pointed, curved scissors (right 
and left) ; uterine hook (Emmet's) for making counter pressure (Fig. 



Fig. 185. — Uterine hook (Emmet's) for making counter pressure. 

185) ; wire adjuster (Fig. 186) ; volsella and tenaculum ; Spencer Wells' 
forceps ; long toothed forceps ; six sponge holders for very small 



Fig. 186. — Wire adjuster. 



sponges ; needle holder and curved needles (from f to 1 in. long) with 
points not too sharp and cutting ; silver wire and carbolic silk sutures ; 
two sigmoid (S-shaped) catheters. 

(/5) Denudation. — The patient is placed in the left semiprone position. 
The fistula is thoroughly exposed, and a strong light thrown on to the 
site of operation by means of Sims' speculum; if necessary the cervix may 
be pulled downwards and backwards by means of a volsella attached to 
the anterior lip. The tenacula are applied at the opposite sides of the 
fistula to ascertain where the least traction will bring the edges together. 



PLASTIC GYNECOLOGICAL OPERATIONS 



IIS 



This being ascertained, the highest point of the fistulous edge is seized, 
either by long toothed forceps or a tenaculum, and placed slightly on the 
stretch. By means of a straight or angular bladed knife (Fig. 184) a strip 
of mucous membrane is then removed entire from the vaginal edge of the 
opening : the blade of the knife should cut in an oblique direction, and 
not touch the vesical mucous membrane, as an injury to it will inevitably 
lead to copious bleeding (Fig. 188, A, B). Some operators use scissors, 
and a combination of both instruments may be necessary in order to 
obtain a raw surface. Any haemorrhage is checked by the intermittent 
hot douche and the pressure of small sponges on holders. 



M 





Fig. 18T. — Mode of freshening the edges of a fistula by "flap-splitting." A. Flaps split and deep 
suture passed but not tied, bl, Bladder mucous membrane ; v, vaginal mucous membrane. B. 
Deep suture tied and superficial one passed. 

Another mode of freshening the edges is by the process of dedouble- 
ment or flap-splitting (Fig. 187, A, B) ; it is useful when the vagina is 
narrow, and there is not sufficient redundant tissue to make satisfactory 
flaps. The raw surface is produced by splitting up the edges of the 

A B 




..u 



•d 




a.-v.w, 



Fig. 1S8. — Mode of passing sutures in vesico- vaginal fistula. A. As seen in semiprone position. S, 
Sims' speculum, blade in section ; c, cervix, secured by tenaculum t ; a.v.ic, anterior vaginal wall ; 
d, denuded surface ; s s, s s,, 1st and last of series of sutures ; u, urethral orifice ; el, clitoris. B., 
As seen in section, bl, bladder mucous membrane ; a.v.tc, anterior vaginal wall ; /, fistulous open- 
ing ; s s,, suture passed but not tied. The shaded areas denote amount of tissue removed in denu- 
dation process. 

fistulous openings, so that the mucous membrane of the bladder and 
vagina are separated all round ; the flaps are brought together separately 



776 SYSTEM OF GYNECOLOGY 

by fine silk. No tissue is hereby lost, but the same accuracy of suturing 
is not possible as by the paring process. 

(y) Passing and securing the sutures. — The needle is first double threaded 
with carbolic silk; a tenaculum seizes the most inaccessible point of the 
denuded surface, and places the tissue on the stretch. By means of the 
holder the needle point is entered on the vaginal surface, about one-third 
of an inch from the raw edge, passed obliquely (Fig. 188) through the 
tissues, and brought out at the bladder orifice of the fistula; great care 
being taken to avoid the bladder mucous membrane. The needle is then 
entered again on the opposite side of the bladder opening of the fistula, 
and passed obliquely through the tissues ; it emerges 
on the vaginal mucous membrane about one-third inch 
from the raw edge, and as nearly opposite the site on 
the other side as possible. Care must be observed 
not to make the point of entry of the needle more 
than half an inch from the raw edge, as the ureter 
may otherwise be included in the ligature. The wire 
suture about ten inches long is now hooked into the 
silk loop and pulled through. 

In order to produce counter pressure on the 
tissues against the needle point, Emmet's blunt hook 
is used as in the diagram (Fig. 189). Care should 
be taken to include sufficient tissue in the sutures. 
A series of these are now passed in a similar manner 
T> ion 1.. -, ^ about one-fifth of an inch apart. The two ends of 

Fig. 189. — Mode of ap- . . .^ 

plying counter press- the Silver Wire are now twisted together by means 
"henredie^rmeans ^^ forccps and a Sims' adjustcr or shield (Fig. 186) 

of a blunt hook (Em an instrument devised for accurate adaptation of 

™^*^'®-" the flap without producing torsion upon the tissues 

(Fig. 190). After all the sutures have been thus secured, they may be cut 
short and the sharp ends either covered with sealing wax or bent over. 
Having ascertained that the denuded edges are in accurate apposition, by 
inspection and by the injection of milk into the bladder, should the 
fistula be quadrilateral in outline the resulting cicatrix will be found to 
be Y-shaped ; if oval, a transverse or longitudinal line will result. Sims' 
sigmoid catheter (a self-retaining instrument) with a long piece of india- 
rubber tubing attached may be introduced, and the patient put back to 
bed. 

(8) After Treatment. — The two chief complications to be encountered 
are haemorrhage into the bladder and cystitis. The catheter should be 
changed daily, replaced by a second, and thoroughly cleansed before 
being used again. It is better for the tube to open into a deep dish 
filled with a 1 in 60 carbolic acid lotion. No other local treatment is 
necessary. The stitches may be removed about the tenth day. 

Such is the operation as carried out by Sims and modified by 
Emmet. 

When the fistula is close to the cervix, and treatment prevented by 




PLASTIC GYNECOLOGICAL OPERATIONS 



r.i 



its presence, it is better to incise the anterior cervical lip or to excise a 
wedged-shaped piece to allow of free inspection and access. The denuda- 
tion should then be freely made around, and, in case of tension, liberating 
incisions are advisable : the sutures should then be passed as before. 




Fig. 190. —Method of fixing and twisting the sutures (Sims'). 



In urethro-vaginal fistula the edges are denuded and sutures passed, 
as in the operation for prolapse of the urethral mucous membrane 
(p. 762). 

(ii.) Simon^s met Jiocl. — This is carried out veryextensively in Germany, 
and differs in many essentials from the preceding. It is fully detailed in 
that author's paper, published in 1 862. Simon attaches less importance 
than did Sims to the preparatory treatment. The semiprone position is 



778 SYSTEM OF GYNECOLOGY 

replaced by an exaggerated lithotomy position, the buttocks being raised 
by a cushion, and the parts exposed by a handled speculum. 

During denudation Simon endeavours to make the fistula a deep 
funnel-shaped aperture, with walls nearly perpendicular (c/. Sims' method), 
and thinks incision of the vesical mucous membrane of no moment. 
Should the fistula be small his mode of suture is somewhat similar to 
that already described ; in the larger varieties, however, he introduces 
two sets of stitches — a deep or relaxing and a superficial set ; the former 
enter and emerge at a considerable distance from the raw surface, and pass 
either close to the bladder lining or pierce it. The latter are passed alter- 
nately with the deeper. Care is taken to avoid inclusion of the mucous 
membrane of the bladder between the flaps. Silk is always used in pref- 
erence to wire, and the sutures are placed very closely together. 

As regards the after treatment the catheter is considered unneces- 
sary, and the patient is allowed to pass the urine herself at whatever 
intervals she likes. Simon is of opinion that the urine has no ill-effect 
upon the healing of the wound, and that distension of the bladder (pro- 
vided the stitches were inserted properly and tied firmly) does not matter. 
There are no restrictions as to diet. The sutures are removed as early 
as the fourth or fifth day. 

(iii.) Boze7iian^s, or the Button-suture method, is again quite different 
from the two already described. The author is most careful in carrying 
out the preparatory treatment, concerning which he claims priority to 
Sims. He commences proceedings by " kolpoecpetasis," or removing 
obstructions to the view of the fistula and to operation upon it. Any 
bands of adhesions are severed, and gradual dilatation is effected by 
means of an elastic bag or glass plug. This is continued until the 
fistulous opening can be well seen, and the edges are soft and lax. 

The position in which he places the patient for operation is a modified 
genu-pectoral one ; that is, she rests upon the knees with the legs apart, 
and the chest and head are supported in a horizontal direction by specially 
constructed cushions. The operator, therefore, sits facing the nates, with 
the anterior vaginal wall downwards. An anaesthetic may be given or 
not, but it is better avoided on account of the awkward position of the 
patient. Bozeman prefers to have little assistance ; and, to attain this 
object, a trivalve speculum is inserted to expose the fistula, which is 
pared in situ ; the uterus is not drawn down by a volsella. 

After paring the edges the sutures are passed in the usual manner, 
and the ends instead of being tied are brought through a perforated 
plate which lies over the line of union, and are then fastened by means 
of perforated shot. An ordinary catheter is inserted into the bladder, 
and the after treatment is as in Sims' operation. 

The special instruments used in this method are depicted in Boze- 
man's original paper, to which the reader is referred. The advantages 
claimed are, that the position of the patient allows better access to the 
fistula ; that the perforated plate gives the margins of the flap more 
complete rest; and, finally, that it also protects the wound from urinary 



PLASTIC GYNAECOLOGICAL OPERATIONS 



119 



and vaginal 



discharges. 



Although, advocated by many surgeons in 
America it has not found much support in Europe, where Sims' and 
Simon's, or a modification of the two, are usually practised. Xeugebauer 
of Warsaw performs the operation in the same position, and with a 
special apparatus for exposing the opening, but omits the use of the 
perforated plate. 

(B.) Elytroplasty was first brought into notice by Jobert of Lamballe 
in 1834 ; it consists in raising a flap from various situations, such as the 
posterior wall of the vagina, the labium, or even the thigh, and suturing 
it accurately to the denuded edges of the fistula. This operation would 
only be necessary when there was much deficiency of tissue ; and it is 
now almost entirely abandoned, in view of the results brought about by 
the preparatory treatment already described. 

(C.) Kolpokleisis, or closure of the vagina below the fistulous opening, 
is resorted to when direct closure of the fistula is found impossible, and 
will be found described on page 780. 

II. Fistulas requiring Special Treatment. — 1. In vesico-utero-vaginal 
01 juxta-cervical Jistulas the cervix is involved, and must be distinguished 
from the vesico-vaginal variety in which the cervix is intact. 

They are subdivided into superficial and deep according to the partial 
or complete sloughing of the anterior 
cervical lip. 

In the superficial form much may 
be obtained by simple denudation and 
suture ; the tissues being extremely 
tough from cicatrisation the freshening 
must be extensive, as a healthy, ])road, 
and pliable surface is more easily 
sutured than a cicatricial and inelastic 




one. ; 

Deep juxta-cervical fistulas are very 
rarely amenable to treatment by suture, 6"'' 
and it is generally necessary to bring 
the posterior lip of the cervix in 
apposition with the vaginal edge of the 
fistula, and stitch the two together. 
The OS uteri, therefore, will open di- 
rectly into the bladder. This operation fig 
has been termed vesico-hystero-cleisis 
by Pozzi. 

2. Vesko-uterine Jistidas may be 
cervical or corporeal. In the cervical form the anterior portion of the 
cervix should be dissected off the posterior or bladder wall to a distance 
above the orifice of the fistula. The anterior lip is split up to the 
cervical opening, and the denuded surface on the posterior bladder wall 
is then sutured in a similar manner to an anterior colporrhaphy, while 
the artificial cervical tear is treated by trachelorrhaphy. 



191. — Juxta-cervical fistula (superficial 
variety). 5, Sims' speculum in section : 
/". fistula; d, denuded area; c, cervical 
canal ; a, anterior lip ; s s,, *' s,, series of 
sutures passed. 



78o SYSTEM OF GYNECOLOGY 

In the corporeal variety such an operation is obviously impossible ; 
and. the only treatment feasible is that of suturing the two lips of the 
cervix together — hystero-stomato-kleisis ; the uterine secretions must, 
therefore, pass through the fistulous opening into the bladder. 

3. Uretc^ro-vaginal Fistulas. — These are frequently complicated by a 
vesico-vaginal fistula. Landau has invented and successfully performed 
the following operation for this condition : The patient is placed in the 
dorsal or left lateral position ; if a vesico-vaginal fistula do not already 
exist, the surgeon makes one by the excision of an oval flap around the 
ureteral opening. A very fine gum elastic catheter is then passed into 
the renal or proximal end of the ureter, and into the urethra through the 
bladder. The genu-pectoral position is now assumed and the edges of 
the fistula denuded ; a series of fine sutures are passed through the flaps 
at right angles to the ureter and tied. The catheter must remain in the 
ureter and urethra for at least eight days. Should union take place the 
ureteral opening into the bladder will necessarily be higher up than in 
the natural condition. In event of failure kolpokleisis, or some similar 
operation, is the only resource open to the patient. 

4. Uretero-uterine fistulas obviously cannot be treated in this manner, 
and the only means of relief to be obtained is by excision of the corre- 
sponding kidney or artificial closure of the vagina or vulva by a plastic 
operation. 

A recent and valuable paper on the treatment of vesical fistulas is 
that by Dr. Winternitz of Tubingen, and is well worthy of perusal. 

The operations so far described for repair of urinary fistulas have 
been '^ direct " methods ; allusion must now be made to the " indirect " 
modes of cure. These consist in closure of the genital canal at a point 
below the site of the fistula, so that the portion of the vagina above this 
becomes a part of the bladder ; menstruation will then take place into 
this viscus. 

Three varieties have been devised : — 

1. Antero-posterior closure of the vulva, or episiostenosis (Vidal), the 

inner surfaces of the labia majora being denuded and brought 
together by sutures. 

2. Complete vulval closure, with the formation of an artificial recto- 

vaginal fistula. 

3. Obliteration of the vaginal canal transversely (kolpokleisis). 

The two former have proved so unsatisfactory that they have been 
practically abandoned. In kolpokleisis, however, in some rare cases, we 
have a valuable operation. The indications for its performance are when 
the loss of tissue is too great to allow of direct suture of the fistulous 
edges ; when there is much cicatricial tissue at the margins of the fistula, 
or when they are adherent to subjacent bone ; lastly, when there is risk 
of wounding the peritoneum. 

Kolpokleisis, or transverse obliteration of the vagina, maybe performed 
in three places according to the situation of the fistula, at the urethral 
portion, that over the base of the bladder, and the fornix. 



PLASTIC GYNECOLOGICAL OPERATIONS 



781 



For the first of these Simon's position is the best, but for the two 
latter the decubitus advocated by Neugebauer is to be preferred. 

A ring is first marked out by the point of a knife on the vaginal 
mucous membrane, below the fistulous opening; sufficient room being 
allowed to avoid the cicatricial tissue always present. Denudation is 
performed on the anterior surface with a sound in the bladder as a guide, 
while the finger in the rectum is necessary during the paring of the 
posterior surface. 



r. V' w. 




Fig. 192. — Kolpokleisis. Surfaces denuded, and one suture passed, v.v.w., vesico-vaginal wall above 
fistulous opening /; t r,, vagina ; r.v.w., recto-vaginal wall ; c, os uteri externum ; u, urethra ; p, 
perineum ; ;•, rectum. 

The sutures of wire or carbolic silk are passed by means of two short 
half-curved stout needles, one at each end ; both are passed from above 
downwards. The anterior needle (Fig. 192) will be entered on the vaginal 
surface, below the fistula, then pass through the substance of the vesico- 
vaginal septum, beneath the denuded area, and out again on the vaginal 
mucous membrane ; the posterior needle will enter the recto-vaginal wall, 
immediately above the edge of the denuded area, pass beneath this, and 
have its exit on the vaginal aspect opposite to that of the anterior needle. 
Several similar sutures are passed, and they are then tied. Great care 
should be taken to avoid injuring the bladder or rectal mucous membrane 
by including either in the loop of the suture. 

The objection to this method is that the vagina being closed, sexual 
connection is impossible; the patient should be warned of this result 
before consent to the operation is obtained. 



782 SYSTEM OF GYNAECOLOGY 

Faecal fistulas may be recto-vaginal, entero-vaginal, or recto-labial. 
Recto-vaginal fistula is an opening between vagina and rectum, and may 
be the result of parturition, when the lower portion of the sutured peri- 
neum has healed after suture, but the upper still remains open. Advan- 
cing malignant disease, rupture from abscess, and various kinds of ulcera- 
tive processes, may also lead to this condition. In cases in which a plastic 
operation is advisable, should the opening be low down, it is better to 
cut through the perineum and re-suture the two flaps after the manner 
already described in complete perineal rupture (p. 747) : if the orifice 
be higher up denudation should be carried out over an area around it, and 
carbolised silk sutures passed as in vesico-vaginal fistulas. 



John Phillips. 



REFERENCES 



1. BozEMAisr. Rsmarks on Vesico-vaginal Fistula, 1856. — 2. Duke, Alexander. 
Biihlin Medical Press, May 9th, 188S. — 3. Duhrssen. Archiv fdr Gyndkol. 1894, 
Bd. xlvii. S. 284. — 4, Emmet. The Principles and Practice of Gynsecology, 1885, p. 
817. — 5. Fritsch. " Ueber plastische Operationen in der Scheide," Centralhlatt fiir 
Gyndkologie, 1885, No. 49, S. 804. — (>. Hesar. Die operative Gynlikologie, 1881, S. 
4()2. — 7. Landau. "Ueber Enstehung, etc. der Harnleiterscheidenfisteln," Archiv 
fiir Gyndkologie, 1876, Bd. ix. S. 42(). — 8. Lefort, Leon. "New Method for Curinj? 
Prolapse of the Uterus," Bull, de Therapeut. Apr. 30, 1877. — 9. Marckwald. " Ueber 
die Keijelmantel-formige Excision der Vaginal Portion," etc., Archiv far Gyndkologie, 
Bd. viii. S. 48. — 10. Neugebauer. " Casuistik von 140 Vesico-Uterinfisteln," Archiv 
fdr Gyndk. Bd. xxxiii. S. 270, and Bd. xxxiv. S. 145. — 11. Shucking. Centralhlatt 
f. Gyn. 1888, Bd. xii. S. 682. — 12. Simon. Uebsr die Heilung der Blasenscheidzn- 
f stein, Rostock. — 13. Vidal. " Obliteration of the Orifice of the Vagina as a Treat- 
ment for Vesico-vaginal Fistula," Ann. de la chir. franc, et etrangere, 1844, p. 208. 
— 14. Webb, R. Curtis. "On Mackenrodt's Operation," Thesis for M.B. degree, 
Cambridge, 1896. — 15. Winternitz. Centralhlatt fdr Gyndkologie, 1895, No. 15, S. 
377, with Bibliography. 

J. P. 



DISEASES OF THE FALLOPIAN TUBES 

Injuries of the Fallopian Tubes. — The Fallopian tubes are tough, and 
no structures in the body are better protected by their position and 
relations. They accommodate themselves, as is well known, to the 
normal changes of the uterus in pregnancy. A wound of a Fallopian 
tube from a dagger or similar weapon would involve, in all probability, 
more serious injuries to neighbouring vessels and viscera than to the tube 
itself. 

A healthy tube is sometimes cut through during an abdominal section. 
I have noticed that it does not bleed very freely ; the blood mostly issues 
from small vessels in the investing mesosalpinx. The serious feature of 
such an injury is the exposure of a mucous canal which may contain 
septic matter. In most cases there is little or no danger even from 



DISEASES OF THE FALLOPIAN TUBES 783 

this source ; still it is best to touch the exposed mucosa with tincture of 
iodine, especially if the surgeon intends to carry out some other part of 
the operation before removing the Avounded tube. It is seldom of any 
use to sew up the injured tube, as it usually has to be removed with 
adjacent diseased structures. 

The experience of countless ovariotomies teaches us that the healthy 
tube bears well the necessary injury inflicted by the ligature of the 
pedicle. The stump seldom sloughs, and when gangrene does occur the 
remains of the tube are not necessarily the seat or the origin of this 
grave incident. In cases of extensive disease of the appendages, on the 
other hand, the unhealthy tissues of the tube do not always tolerate the 
ligature. Sometimes the silk, when tightened, cuts through the tube. 
The real danger in such a case is not haemorrhage, but exposure of the 
mucosa, as explained above ; suppuration around the ligatured stump is 
not unknown. 

Atrophy and Hypertrophy of the Tube. — After the menopause the 
tube shares in the atrophic process which involves the uterus. It like- 
wise undergoes a certain amount of involution after pregnancy. The 
term atrophy cannot be applied to the arrested development of a mal- 
formation. In subjects who have died from chronic wasting diseases the 
tube is often found like a piece of thin twine, the fimbriae being reduced 
to small, very pale, red shreds. In twisting of an ovarian pedicle atrophy 
of the tube may proceed to such an extent as to reduce it to a thin cord. 
In extreme cases the entire pedicle may part in the middle, and the uterine 
as well as the distal end of the divided tube is then always found in a 
state of extreme atrophy. The dragging of an omental adhesion may 
cause stretching and atrophy of the tube. As a rule adherent omentum 
is dragged down ; but in exceptional cases the omentum may pull up 
the tube and stretch it considerabl}^ I have observed two cases where 
this condition Avas well marked, the tube being atrophied. 

Perimetritic bands pressing on the tube may bring on local atrophy, 
with obstruction of the lumen. Extreme atrophy of the tube may be 
occasioned by pressure between the pelvic wall and a large fibroid of 
the uterus. 

Hypertrophy of the tube is a physiological condition in pregnancy. 
It must be remembered that in a healthy young woman the tube is a 
stout, deep red, tortuous, worm-like structure, with thick budding fimbriae 
almost as big as the petals of a small carnation. Inexperienced operators, 
whose notions of a "normal" tube are based on the examination of 
dissecting-room subjects, or specimens shrunken from the action of spirit, 
may regard a healthy tube as diseased, or at least hypertrophied. True 
hypertrophy of the tube occurs when a myoma develops in the uterus 
near the cornu, and in all cases of large " fibroids " where the tumour 
does not press the tube against the pelvic wall. In ovarian cystic disease 
and in other pedunculated pelvic tumours the tube certainly grows 
longer, but it is not the essential tissues that undergo hypertrophy. I 
have always found that the mucosa appears more or less atrophied, the 



784 



SYSTEM OF GYNECOLOGY 



fimbrise being often much reduced in size. A yet more extreme condi- 
tion is seen in the simple broad ligament cyst and other non-peduncu- 
lated tumours of the pelvis, where the tube undergoes great stretching 
and a certain amount of hypertrophy, in which the mucosa assuredly 
takes no part. 

Hypertrophy of the muscular coat occurs in some forms of salpingitis. 

Inflammation of the Tube or Salpingitis. — The earlier essential and 
purely local changes which occur when the tube is inflamed will be con- 
sidered in the following paragraphs. These changes affect the coats of 
the tube and the ostium. The remarkable complications which follow 
when the disease is well established will be fully discussed in the section 




Fig. 193. — Section of a healthy tube from a young- subject. The corresponding ovary was removed, as 
it showed signs of incipient cystic disease. The opposite ovary formed a large tumour. The phcae 
are delicate and well formed ; very large vessels run in the muscular coat. (Beck, \ inch.) 

on pelvic inflammation. Here I need only note that amongst these 
changes are hydrosalpinx, pyosalpinx, and the rarer forms of hsemato- 
salpinx. The union of the cavity of a tube which has become cystic 
with the cavity of a cyst of any kind in the adjacent ovary produces the 
commoner form of tubo-ovarian cyst, which is to be distinguished from 
the teratological condition to which Mr. Bland Sutton has given the 
name of "ovarian hydrocele." The development of the first or inflam- 
matory variety was described by myself in 1887 (156). Sutton makes 
the same distinction, or rather goes farther, and denies that an ovarian 
hydrocele is a " tubo-ovarian cyst " at all. 

In the paragraphs on new growths of the tube, however, I shall return 
to the subject of salpingitis, bringing forward evidence that these new 



DISEASES OF THE FALLOPIAN TUBES 



785 



growths specially affect tubes which have long been subject to inflamma- 
tion. Indeed, it will be shown that papilloma, itself prone to undergo 
malignant degeneration, seems to originate amongst inflammatory prod- 
ucts. 

The observer, when studying sections of diseased Fallopian tube, must 
avoid the common error of taking normal for morbid appearances. Nor 
must he conclude that the presence of normal amongst morbid tissues 
necessarily implies that the disease is not advanced. The columnar 
epithelium lining the plicae in health is, of course, perfect ; but it is by 
no means the first structure to be distinctly affected by the inflammatory 



^^: 



-.-/rh 






" -AT- 



» 



Fig. 194. — One of the plicse in Fig. 193, as seen under a J incli objective. It is slender and well formed ; 
its surface is invested with columnar ciliated epithelium. 

process. In health large vessels with stout coats are to be found in the 
plicse and at their roots. These vessels undergo changes, in relation to 
the menstrual cycle and pregnancy, not yet perfectly determined. In 
inflammation they tend, I find, to become obstructed rather than en- 
larged. The pathologist must not forget that in tubes removed by 
operation any marked change in the blood-vessels may be due to the 
ligature. 

The naked-eye appearances in the earlier stages of salpingitis are 
not very distinct, even when the microscope can already reveal marked 
changes. A highly vascular appearance of the tube may be due to 
menstruation or the ligature, and a considerable amount of mucus 
may be seen in the healthy tubes. Exuberant fimbriae are evidence 
of health and vigour, not of disease ; the fimbriae in inflammation tend 
to shorten and retract, as will be explained further on. 

3e 



786 SYSTEM OF GYNECOLOGY 

In early salpingitis the most prominent feature is small-celled infiltra- 
tion of the plicae, which causes them to become thick and club-shaped. 
(Compare Figs. 193 and 194 with Figs. 195 and 196.)^ 

The blood-vessels, at first perhaps dilated, soon ajjpear narrower than 
in health. There is no rapid desquamation of the epithelium ; indeed, 
this change need not take place at all. Mucoid degeneration of the cells 
is not rare ; Weichselbaum admits its existence. It will be shown, how- 
ever, that in advanced salpingitis the epithelium persists in certain places. 
Even when the inflamed tube becomes obstructed and dilated for months 
or years the epithelium may reiuain intact. In that case, as in less 




Fig. 195. — Section, near the ostium, of an inflamed tube. The plicfe, normally very slender in this part 
of the tube, are thickened by small-celled infiltration (\ inch objective). 

chronic disease, the cells become low and cubical, and lose their cilia (Fig. 
197). The nuclei become large and spheroidal, nearly filling the cell. 
Schramm describes this appearance as occurring early in tubercular dis- 
ease of the tube. 

A characteristic change, peculiar for evident reasons to salpingitis, 
soon follows. This change is the adhesion of the edges of adjacent 
fimbriae. The small-celled infiltration presses the swollen edges together, 
and the epithelial surfaces thus in contact become destroyed, so that the 
cells disappear by a purely secondary change quite unlike what is under- 
stood by catarrhal desquamation. The plicae, however, remain apart 
near their roots. Here the epithelium remains intact, another proof how 

1 The photo-micrographs illustrating salpingitis were kindly taken by Mr. Edmund 
Roughton and Mr. H. Cosens from sections of diseased tubes which I have removed by 
operation. I have been careful to select cases where the clinical history was very clear. 



DISEASES OF THE FALLOPIAN TUBES 



787 




Fig, 



196. — Section of a plica (same case as Fig'. 195), sho-s^ing the earlier changes seen in salpingitis. It 
may be compared with the healthy plica, Fig. 194. Small-celled infiltration has taken place, caus- 
ing distinct thickening, especially towards the free edge. The epithelium is intact. {\ inch 
objective.) From a woman aged 33, subject to pelvic inflammation for about seven years. The 
appendages were removed and advanced disease discovered. The portion here seen displays the 
ctt'ect of a recent attack of inflammation over an area which had previously escaped disease. 




Fig. 19T. — Section showing the free surface of the interior of a tube Avhich had been obstructed and 
dilated for a long period. From a woman aged 42, who had sufl'ered for over ten years from chronic 
pelvic inflammation. The epithelium has not disappeared, but the cells have become cubical and 
have lost their cilia. The middle coat is reduced to fibrous tissue ; the vessels and muscular fibres 
have entirely disappeared. (| inch objective.) 



788 



SYSTEM OF GYNECOLOGY 



little it is subject to primary change in salpingitis. In consequence of 
the adhesion of the plicae along their edges spaces, often lined with per- 
fect epithelium, appear in sections. There can be no doubt about the 
fusion of plicae ; many independent observers have noted it : this being 
the case there is no mystery about the spaces lined with epithelium ; 
they are in no sense cysts at first, but they often become so after a time, 
when a long and broad area of plica3 sinks embedded in inflammatory 
effusion. The observer must not confound this pathological union of 
plicae with the normal union of the tips of plicae sometimes seen in 




Fig. 198. — Section of an inflamed tube, in its middle third, showing- active inflammation, more advanced 
than in Fig. 196. The small-celled infiltration is marked, the free edges of the plicae are much 
swollen. To the left they are becoming fused and their epithelium is disappearing. 

healthy tubes. Nor must the cut-off spaces be taken for the teratological 
diverticula (Whitridge Williams), not rare in tubes otherwise normal. 
These diverticula contain healthy plicae. 

In the middle coat oedema, separating the muscular fibres, is very 
frequent; and the small-celled infiltration is constant. The oedema is 
the chief factor in obstructing the ostium from within, — the " salpingitic 
closure of the ostium," — of which more will be said presently. The 
inflammatory infiltration may end by organising so as to form fibrous 
tissue which makes the tube feel tough. The " kinking " of the tube, 
so often described, is usually a congenital condition, not rarely due to 
shortness of the mesosalpinx. It is always increased by this sclerosis 
of the middle coats, and by perimetritic changes without. As the outer 
or serous coat of the tube is part of the peritoneum, its changes in in- 
flammation are those seen in peritonitis. 



DISEASES OF THE FALLOPIAN TUBES 789 

The more advanced form of uncomplicated inflammation of the 
tube should be called purulent salpingitis. Pyosalpinx implies also 
closure of the tube : in purulent salpingitis the ostium is usually, but 
not always closed. I have seen pus issuing from the open ostium of 
a tube not greatly enlarged ; this was the case in the specimen from 
which Fig. 198 was prepared. Hartmann and other observers describe 
the same appearance. 

Under the microscope the plicae are found thickened by infiltration 
of round cells (Fig. 199), and reduced in length. The epithelium on 




Fig. 199. —The free surface of the interior of a suppurating tube. The plicae are extremely thickened, 
but not all fused together. The deeper parts were less vascular than in health ; the muscular coat 
was h3'pertrophied. From a woman aged 44, subject to symptoms of pelvic inflammation for four 
years : very severe for four months before operation. Double pyosalpinx was discovered. 

the surface is always lost, to a great extent, but deeper down are spaces 
in which it usually persists (Fig. 200). In short, we see an advanced 
stage of the changes already described. In part, however, as in Fig. 
200, there is evidence of actual breaking down of the diseased plicae, 
granulation tissue appearing on the free surface. When pyosalpinx 
exists the diseased mucous surface is ultimately opened out by the 
stretching of the walls of the obstructed tube; thus it suffers further 
damage, and may be entirely reduced to a surface of granulation tissue 
— to an abscess wall, in fact. Yet experience shows that even in long- 
standing pyosalpinx the epithelium is not always destroyed. 

The plicae in purulent salpingitis, reduced to low tuberous elevations 
(Fig. 198), are far less vascular than in health; though a few abnor- 
mally thick-walled vessels remain. Many vessels disappear, doubtless 
through pressure of inflammatory products. 



790 



SYSTEM OF GYNECOLOGY 



The middle coat is always more or less infiltrated with small cells 
in purulent salpingitis. Sometimes there is actual hypertrophy of the 
muscular fibres ; more often an increase of connective tissue is observed. 
In consequence the middle of an affected tube, with its low plicae and 
thick walls, often looks like the uterine end of a healthy tube (Fig. 198). 

A general atrophy of the affected structures in the tube may and often 
does follow long-standing inflammation (Fig. 197). More frequently 
the long-diseased tube shows several stages of inflammatory change 
simultaneously. A tract of granulation tissue may be bounded on one side 
by dense cicatricial fibres, showing atrophy of the structures involved ; in 




Fig. 200. — Section of a suppurating tube, showing advanced disease. Fusion of the plicje is complete, 
and much granulation tissue lies ou the free surface of the mucosa. The cysts, or pseudo-cysts, 
representing the spaces between the roots of the plicae, have not lost all their epithelium. From a 
woman aged 2G, subject for three years to pelvic inflammation. Seven months before the append- 
ages were removed the curette was applied to the uterine cavity. The patient disregarded advice, 
got up too soon, and an acute attack occurred with high temperature. Both tubes were found 
full of pus. 

another direction it may impinge on plicae which seem almost healthy, 
resolution having evidently taken place. I find that these irregular 
appearances are the rule. Spaces actually cystic are usually observed 
in advanced salpingitis. Sometimes they seem to be of lymphatic origin. 
The presence, however, or rather the persistence of epithelium in many 
of these cysts proves their true nature, which has already been explained. 
It is easy to understand why these changes proceed irregularly ; for 
in the clinical history of any chronic case we know that exacerbations are 
common, and that enforced rest ensures a certain or uncertain degree of 
amelioration. Subsequent neglect makes matters worse, and the disease 
once more advances. When a pyosalpinx is established the pus may 



DISEASES OE 7 HE EALLOPIAN TUBES 



791 



not press on the tubal walls with any degree of steadiness ; indeed, it 
may occasionally escape into the uterus, so that for a time the condition 
which constitutes pyosalpinx ceases to exist. In other cases the pressure 
may be steady, but the pus degenerates into a watery fluid, and the mucosa 
and muscular coat into more or less pure fibrous tissue. 

In consequence of the irregular course of the inflammatory process 
the appearances in diseased tubes are very puzzling. Hence intricate 
forms of classification have been devised, not always on truly scientific 
principles. The dilated cystic cavities sometimes convert the tube into a 
strange-looking structure ; and when the tube is extremely contorted, it 
may appear on section to have more than one lumen. Tracts of hyper- 
trophied muscular tissue sometimes present an unusual appearance, but 
the muscle cells may here represent a new growth rather than an inflam- 
matory product. I shall refer to this subject in my observations on 
myoma of the tube. 

Changes in the Ostium. — The abdominal end of the tube is not 
necessarily obstructed even in chronic salpingitis. I have seen an open 
ostium in advanced suppurative inflammation, which is one reason why 
that term must not be used as identical with "pyosalpinx." In these 
cases the general peritoneal cavity is protected from the pus by peri- 
metritic bands near the ostium which, though actually open, can only 
pour its contents into a narrowly limited space. 

As a rule, however, the ostium in salpingitis becomes more or less 
obstructed and more or less permanently closed. The obstruction may 
arise from without or from within the tube. 

To obstruction from without I have applied the term " perimetritic 
closure of the ostium." In this condition the outer coat, which is part 
of the peritoneum, is affected. The adjacent peritoneum may be inflamed 
before the tubal mucosa is involved. A little deposit covering the delicate 
fimbriae as they lie on the surface of the outer aspect of the ovary is 
sufficient to bind them down, and when the deposit is organised the ostium 
becomes firmly closed. In ascites, and especially in ruptured ovarian 
cyst, I have seen the fimbriae assume the form of chalk-like wattles. 
This is probably a result of inflammation and of simultaneous deposit of 
salts from the morbid fluid. Diseased fimbriae are eminently adapted 
to receive fibrous deposit (15^). Sometimes, on scraping away bands of 
lymph in the course of an operation, the fimbriae come in sight, well 
formed and bright red, being full of blood. In such cases little or no 
salpingitis may be present. As a rule, however, when its ostium is 
closed from without in this manner the tube is actually the seat of 
inflammation ; and the perimetritis which causes the closure is the 
result of extension of inflammatory processes from the tubal canal. 
This extension protects the peritoneal cavity even more completely 
when the ostium is directly closed than when it remains patulous, 
yet cut off from the great serous cavity in the manner explained 
above. 

The accompanying sketch (Fig. 201) represents a characteristic exam- 



792 



SYSTEM OF GYNECOLOGY 




pie of purely perimetritic closure of the ostium. The well-formed and 
exuberant fimbriae were packed in a deep pouch, on the outer side of 
the ovary, formed by a firm band of membrane. In the drawing the 

fimbriae are displayed as they appeared 
when pulled half out of the pouch. The 
ostium, before the parts were disturbed, 
lay deep in the pouch, completely 
obstructed. The tube was tortuous, 
being kinked by some firm perimetritic 
bands ; it was also the seat of salpin- 
gitis, but the ostium was not closed by 
changes in the mucosa. 

To obstruction from within I have 
applied the term " salpingitic closure of 
the ostium." By causing the accumu- 

FiG. 201. -Ovary and tube showing obstruc- latiou of mUCUS or pUS witMu, it is the 

tion of the ostium by a perimetritic niost important agent iu the establish- 

band which forms a deep pouch. The , p-^, i i • ^ i • 

fimbriae have been partly pulled out of mCUt Ot hydrosalpinx and pyOSalpiUX. 

the pouch. A bristle passes into the j^ occurs in a large proportion of the 

pouch out of the ostuim. . . '^ n-n 

cases 01 salpingitis. The mucous mem- 
brane and the middle coat become greatly thickened by inflammatory 
processes already described; they swell and bulge round the ostium, 
and ultimately close over it. The fimbriae do not retract like the 
tentacles of a sea-anemone; the infiltrated tissues simply close over 
them, till they lie reduced to plicae 
inside the tubal canal. A glance at 
Fig. 202 will show the difference of this 
form of obstruction from that already 
described. Around the bristle the 
thickened tubal walls bulge high, the 
oedematous ovarian fimbria alone re- 
mains outside. The perimetritic bands 
behind and above the bristle must not 
be mistaken for fimbriae. When the 
bulging structures touch and adhere 
over the side of the ostium the obstruc- 
tion becomes very firm. 

Owing to the anatomical characters fig. 202 
of the part, stricture of the uterine 
end of the tube, after the manner in 
which the ostium is so often closed, 
is impossible. A firm perimetritic band may press on the outside of 
the tube near the uterus ; more frequently the uterine end is closed in 
salpingitis simply by the swelling of the mucous membrane. 

The natural tendency of an obstructed tube is doubtless towards cure 
by spontaneous relief of the obstruction. The liability of the patient to 
repeated attacks of pelvic inflammation often prevents spontaneous cure. 




Tube showing obstruction of the 
ostium from inflammatory swelling of its 
coats. The end of the tube has been drawn 
up from the ovary and the ostium forcibly 
opened ; a bristle lies in its orifice. 



DISEASES OF THE FALLOPIAN TUBES 793 

Very extensive changes follow chronic obstruction, some of which are 
described in the chapter on pelvic inflammation. Others, more severe, 
I will dwell on presently, and show how an inflamed tubal mucosa may 
become papillomatous ; and how the new growths may undergo cancerous 
degeneration. 

Closure of the uterine end by simple swelling of the mucous mem- 
brane must obviously be relieved when the swelling subsides ; it is 
not apt to be so permanent as salpingitic or perimetritic closure of the 
ostium. Temporary subsidence of the swelling of the mucosa at the 
uterine end fully accounts for '• hydrops tubae profluens." The ostium 
remains in these cases firmly closed, but the fluid in the tube rushes out 
of the uterine end and escapes externally. 

This condition, termed " hydrops profluens," may be caused by simple 
hydrosalpinx, by congenital tubo-ovarian cyst (" Ovarian hydrocele " of 
Bland Sutton), or by growths within the tube, as in No. 5 in the 
papilloma series, and No. 15 and No. 17 in the cancer series. Great 
quantities of fluid may escape. The term " hydrops tiibse profluens " 
indicates rather a symptom than a definite disease. The symptom, as 
the above observations indicate, may be of grave import. 

Tuberculosis of the Tube. — This interesting disease has attracted 
much attention since chronic affections of the appendages have been 
studied in a scientific manner. For precise information on its essential 
nature we must rely upon the bacteriologist and authorities on tuber- 
culosis. The affected tissues undergo changes which deserve some 
consideration in these pages. The proportional frequency of tubercle 
of the tube has not been accurately determined. The statistics of sev- 
eral living authors show great discrepancies, whether in respect to the 
proportion of cases detected in long series of autopsies, or in regard 
to the number of tubercular tubes discovered in operations for the 
removal of diseased appendages. Of all parts of the female genital 
tract, the tube, no doubt, is the most often affected. 

Tuberculosis may involve the Fallopian tube long before puberty. 
])r. W. C. Chaffey has described a case where a child aged four died 
with tubercle in the lungs and abdominal organs. The Fallopian 
tubes formed two nodular masses, each about the size of a filbert; 
the tubal wall bore caseous deposit on its inner aspect. Dr. Quarry 
Silcock detected a similar condition in a child aged five, who died 
of tubercular meningitis following cough and otorrhoea; the lungs 
and peritoneum were also involved, and the Fallopian tubes were 
enormously distended with caseous material. These two cases are of 
clinical importance, as they may throw light on the significance of 
tubercular salpingitis in virgins. Dr. Cullingworth states that tubal 
disease in the virgin is generally, if not always, tubercular: in such 
subjects, it is, at any rate, very frequently tubercular, and then often 
appears as though primary. Nevertheless, as in Chaffey and Silcock's 
cases, in infancy the patient may have suffered from tubercle elsewhere. 
An organ primarily involved may recover from the tubercular affection. 



794 SYSTEM OF GYNECOLOGY 

A secondary deposit in the tube may presumably remain latent until 
puberty. 

Infection of the tube in a patient already tubercular can well be 
understood. Jani found the tubercle bacillus in the mucosa of a tube 
from a patient who had succumbed to chronic phthisis and tubercular 
disease of the intestine: the tube was jjerfectly healthy. Thus the 
specific germ may be widely diffused without necessarily involving 
every structure to which it pays a visit. The tube may be invaded 
and infected through the circulatory system. Tuberculosis of the 
peritoneum and intestines is a well-recognised source of the disease in 
question. Invasion of the tube from the lower part of the genital tract 
is rare. 

Pathologists seem fairly agreed that the Fallopian tube may be the 
seat of primary tubercle ; but in any suspected case we must bear in mind 
the qualification made above in reference to Chaffey and Silcock's obser- 
vations. Martin and Orthmann, writing in 1895, assert their belief in 
direct infection from without, the vagina and uterus escaping damage 
from the germ. The bacilli may be introduced by instruments, by the 
explorer's finger, and, it is believed, by the seminal fluid in coitus. 
Whitridge Williams, on the other hand, does not think that it has ever 
been satisfactorily proven that genital tuberculosis occurs as the result of 
infection by coitus. Menge's case is attributed to this cause, chiefly on 
the strength of the fact that the disease appeared shortly after marriage. 
The husband, it is true, "was known to have genital tuberculosis," but he 
" refused to be examined." Of course, if the tubercular history had related 
to himself and to his relatives only, and not to his wife's also, Menge's 
theory would have been almost proved. I find, however, that Menge 
admits that the patient's father had succumbed to phthisis, five sisters 
had died at an early age and were reported as scrofulous ; and, above all, 
the patient was laid up when six years old with ascites and some visceral 
disease. She had also been subject to swollen glands. This history 
implies primary infection elsewhere than in the tube. Tubercular 
pyosalpinx was no doubt detected, and the peritoneum was studded 
with tubercular deposit. The apparently complete recovery of the 
patient a few months after the removal of the tubes is no proof that the 
primary seat of tubercle was extirpated ; it is but an interesting example 
of the disappearance of the symptoms of tubercular peritonitis after sim- 
ple opening of the abdominal cavity. Penrose and Beyea definitely state 
that they have detected primary tuberculosis of the tube in three cases, 
and their diagnosis was made or confirmed on abdominal section. The 
patients seem to have recovered. Yet, in one or more of these cases, 
older deposits of tubercle may have existed in other organs. 

Dr. Whitridge Williams is the author of the best synoptic work od 
tuberculosis of the female genital organs. He is wisely cautious about 
the question of primary infection. " The majority of cases are secondary 
to tuberculosis elsewhere, and are due either to infection from the blood 
or the neighbouring organs. Even in the apparently primary cases it is 



DISEASES OF THE FALLOPIAN TUBES 795 



impossible to exclude blood infection." I agree entirely with Dr. 
Williams in his cautious decision. 

Pathology. — Hard as it is, for evident reasons, to procure a tube in 
the earliest stage of ordinary salpingitis for examination, it is still harder 
to obtain evidence of the initial changes in the tubal tissues after tuber- 
cular infection. The bacillus, as above noted, has been seen in a still 
healthy tube in a phthisical subject. Schramm gives a good description 
of incipient salpingitis due to tubercle. I have always found that, 
with important modifications, advanced cases resemble advanced salpin- 
gitis of other kinds. As I find in ordinary inflammation of the tube, 
the epithelium, according to Schramm, is not shed even when the tuber- 
cular disease is already definite. The cells swell and sometimes lose 
their cilia, but they are slow to fall. The essential primary change is a 
diffuse cell-growth of lymphoid and epithelioid character in the plicae, 
which become greatly swollen. Cheesy metamorphosis of this cell- 
growth speedily follows, the change beginning in the nuclei of the 
epithelioid cells. Schramm notes that the epithelium at first appears 
swollen ; and the nucleus, greatly enlarged and spherical, fills up nearly 
the whole breadth of the cell. This change, however, is precisely what I 
have seen in ordinary chronic salpingitis. It is represented in Fig. 197, 
p. 787. The patient in this instance was free from any sign of tuber- 
cular disease, and remained so two j^ears after the parts were removed. 

When caseation takes place Schramm finds that the epithelium disap- 
pears. Thus its destruction is a secondary, and almost a purely passive 
process, which I make out to be the case in ordinary salpingitis. The 
diffuse cell-growth invades the muscular coat. The thickening and 
subsequent breaking down of the infiltrated tissues is a process which is 
easy to observe ; it is seen in tubes where the disease is more advanced 
than in Schramm's specimens. In Mlinster and Orthmann's fine drawings 
of chronic tubercular salpingitis the appearances are much the same as 
in the chronic non-tubercular form, shown in Fig. 200, p. 790. There 
are the same cyst-like spaces lined with epithelium. There is, of course, 
this essential distinction, that the stroma in Munster's specimens is not 
only subject to small-celled infiltration, as in uncomplicated salpingitis, 
but it is also infested with giant cells and other characteristic elements 
of tubercular disease. Thus precise observation shows that both in the 
earlier and later stages tuberculosis of the tube is, to say the least, 
intimately allied with salpingitis. 

I think that great attention should be paid to Schramm, jMiinster, 
and Orthmann's researches ; since they show that in the early stage of 
tubercular disease of the tube it is the mucous membrane and adjacent 
tissues that are first attacked, and that the disease is inflammatory — in 
fact a form of salpingitis. Martin and Orthmann find "acute catarrh" 
in acute tuberculosis of the tube, whilst the chronic form of the same 
disease, if the ostium be closed, is, according to their researches, practi- 
cally suppurative salpingitis or pyosalpinx. Whitridge Williams' fifth 
case is a possible exception ; the entire tubal mucous membrane was 



796 SYSTEM OF GYNECOLOGY 

studded with, miliary tubercles of very small size, but no accompanying 
inflammatory change could be detected. Perhaps after all this is the 
earliest stage of tuberculosis of the tube. The specific cell-growth in- 
vading the mucosa speedily irritates surrounding tissues, and salpingitis 
is the result. On the other hand, previous inflammation assuredly 
renders the tube more liable to be damaged by the tubercle-bacillus. 
As in tubercular disease of the epididymis and testis, gonorrhoea cer- 
tainly disposes the tube to infection from the tubercle-bacillus. This 
subject is familiar to the bacteriologist, and mixed infection has already 
been recognised. 

When tubercular peritonitis exists, invasion of the tube from with- 
out is easy to understand. So long as the serous coat alone is involved 
the disease is tubercle on the tube rather than tubercle of the tube. 
The deeper coats, however, are soon invaded. I have frequently ex- 
amined such tubes and never found inflammatory changes absent. 

The naked-eye changes are not hard to detect when the tubercular 
disease is advanced. The tube assumes the characters seen in severe 
pyosalpinx ; its dilated cavity nearly always contains pus. The coats, 
much thickened, show abundant cheesy deposit. Free adhesions to 
adjacent structures are the rule. Atrophic fibroid changes have been 
noted by some writers. The tubercular tube becomes extremely tortu- 
ous and, if unobstructed, remains so. 

Symptoms and Diagnosis. — When a history of tubercle exists diag- 
nosis is not usually difficult; but when chronic inflammation of the 
appendages occurs in phthisical subjects and in patients with ample 
evidence of tubercle, the tubes may remain unaffected by the specific 
germ. Hence salpingitis in tubercular patients must not be recklessly 
reported as tubercular. 

The presence of a tender swelling in one or both lateral fornices in 
a tubercular subject is fair evidence, I admit, of disease of the tube due 
to the general infection. Tubercular salpingitis is often, I find, a very 
chronic disease, less painful than the non-tubercular form. Some writers 
speak of pain as a special feature; but this, I believe, is due to strong 
adhesions which interfere with neighbouring organs. Ultimately the 
condition is the same as in neglected pyosalpinx from other causes, and 
fistulas discharging pus aggravate the patient's condition. The ill 
health may at first cause amenorrhoea. As a rule, however, menstrua- 
tion is profuse and painful, a symptom caused in many instances, I be- 
lieve, by tubercular changes in the endometrium. T. S. Cullen (9a) 
finds that "there may or may not be irregularity of menstruation" in 
the disease which he describes. He finds that it is generally secondary 
to tuberculosis of the tubes. Ascites is very frequent in tubercular 
peritonitis ; hence when pelvic exploration in a young subject with 
ascites, not due to visceral disease, exhibits evidence of enlarged or 
inflamed tubes, these structures are very probably tubercular. 

Evidence of gonorrhceal infection added to symptoms and clinical 
records indicating tubercle of the tube greatly increases the probability 



DISEASES OF THE FALLOPIAN TUBES 



797 



of the latter. In one case where I operated this kind of infection was 
admitted by the patient's husband, in a second it was self-evident. The 
pathology of this complication is discussed above. 

Treatment. — When the disease is apparently confined to the tube the 
removal of the morbid structure is decidedly indicated. The extirpation 
of an active focus of tubercle is very advisable. 

In more doubtful cases exploratory incision is quite justifiable. In 
many cases of disseminated tubercle the opening of the peritoneum proves 



LF.t 




RF.t, 



Ut.cav 



Fig. 203. — Tubes and uterus from a patient who died of phthisis three years after incision of peri- 
toneum infected with tubercle. (See Trans. Obst. Soe. vol. xxxi. p. 217, and vol. xxxiii. p. 185.) 
R.F.t., L.F.t., Right and left Fallopian tubes. Ut. car., Uterine cavity. A bristle passed into 
each tube. li.Uit., L.Urt., Eight and left ureter. Vag., Upper part of vagina. Ur., Urachus, 
abnormal. 



in itself beneficial. In two cases in which I incised a tubercular peri- 
toneum, but did not remove the diseased appendages, the abdominal 
symptoms subsided. One patient died of phthisis three years later; 
the tubes were found diseased, yet in a quiescent condition (Fig. 203). 
The other is still living, four years after the operation ; she presents 
practically no objective or subjective pelvic symptoms : one knee remains 
weak from an attack of synovitis which occurred during convalescence 
from the operation. 

Hydatid Disease of the Tube. — M. Doleris {La gynecologie 1896, p. 
97) recently operated on a butcher's wife, successfully removing both her 



798 SYSTEM OF GYNECOLOGY 

tubes, wliich. formed a pair of large convoluted tumours stuffed witli 
hydatid cysts. 

Actinomycosis of the Tube. — This disease has been more talked 
about than observed, as it was the cause, a few years since, of a dispute 
between two authors. There can be no doubt that in Zemann's case, 
so often quoted, the tube was the seat of actinomycosis. Zemann's 
report is thus summed up by Dr. Illich in his recent monograph on 
actinomycosis : — 

" A cook, aged forty, taken ill with symptoms of peritonitis. Death 
after meningitis had set in. A few coils of intestine were found bound 
by a firm and widely diffused deposit to the right tube, which was con- 
verted into a sac as thick as a finger, full of pus and lined with 
granulation tissue containing actinomyces. Metastases in brain, lung, 
and liver. The author (Zemann) traces the infection to the genitals. 
Israel suspects that the infection more probably proceeded from the 
intestine. The deposit above mentioned indicates, in our opinion, the 
way of infection." The fungus was only found in the tube, and not in 
the metastases, a fact which would seem to favour Zemann's opinion. 
Illich, however (1892), stated that in no case of actinomycosis of the 
abdomen, published since Zemann's report (1883), has there been the 
slightest evidence of infection through the genitals. Sir T. Grainger 
Stewart, nevertheless, writing in 1893, brings forward evidence which 
we must not disregard. In his case the patient died with symptom^s 
of ursemia, and both ovaries were infected with the parasite; colonies 
of actinomyces were found in the pus which filled a dilated portion of 
the right Fallopian tube. Stewart concludes that the mode of entrance 
was by the vagina and uterus. " The strict localisation of the disease 
on the right side to the ovary, and the presence of the parasite in the 
corresponding Fallopian tube, afford practically conclusive proof that 
the disease had spread along the tube." In a patient aged thirty-six, 
under Illich's observation, a mass was felt in Douglas' pouch. An 
exploratory operation proved disastrous. This seems always to be the 
case in peritoneal actinomycosis, as the disease is widely diffused before 
marked symptoms set in. A cyst containing characteristic deposit was 
found on each side of the uterus. It is not stated whether these cysts 
were tubal, in fact no mention is made of the tubes. The intestines, 
liver, and lungs were infected with actinomycosis. [ Vide art. "Actinomy- 
cosis," Syst. of Med., vol. ii. p. 81.] 

Should actinomycosis of the tubes be suspected, he must follow 
better's advice, and prescribe large doses of iodide of potassium. That 
drug, so useful when the same disease attacks cattle, has cured two 
cases of actinomycosis of the lung and caecum respectively in the human 
subject. Cart of Paris (1894), therefore, maintains that we must trust 
to iodides rather than to the knife. Choux (1895), though he gives full 
credit to Netter, is more inclined to rely on surgery than on salts, but 
he brings forward no clinical evidence to support his preference. 

Fibroma and Enchondroma. — The existence of a solid tumour of the 



DISEASES OF THE FALLOPIAN TUBES 799 

tube which can be strictly placed under either of the above denomina- 
tions is very doubtful. The first term is often loosely applied in works 
on the pathology of the female organs. By "fibroid" many writers 
mean not so much a tumour as the disease where a myomatous tumour 
has developed in the uterus. Hence it is natural that " fibroma/' still 
a purely pathological term, should be sometimes used in error for 
" fibroid," a word which is now generally used in a clinical sense. By 
'^fibroma of the tube," then, certain writers really mean "myoma," a 
new growth of which something will presently be said. 

On the fimbriae it is not rare to find small, semi-transparent bodies 
looking and feeling like fragments of cartilage. Bandl states in his 
text-book that he has observed them : he speaks of them as " connec- 
tive-tissue growths hard as cartilage." Mr. F. S. Eve has reported more 
explicitly on a specimen of this kind of growth. " Each nodule contains 
two, three, or more circumscribed structureless (except for the occasional 
appearance of faint lamination) yellow masses, apparently in part cal- 
cified ; the edges of some of the nodules are crenated. The surround- 
ing connective tissue is very rich in large round cells. Of the nature 
and mode of origin of these masses I can offer no opinion. They are 
neither cartilage nor bone." The specimen is preserved in the patho- 
logical collection at the Museum of the College of Surgeons (^0. 4584 a). 
I believe that they are identical with the very similar bodies found in 
ordinary papilloma of the ovary, which cause the mass to feel gritty. In 
examining Sir Spencer Wells' case of papilloma of the tube, a few years 
before Mr. Eve described the cartilage-like bodies, I found that the cells 
of the stroma near the apex of a papilla resembled cartilage-cells. 

Kossmann and Whitridge Williams may hold that the above facts 
confirm their opinion that true papilloma of the ovary is derived from 
tubal elements. They do not confirm the opinion that true enchondroma 
of the tube has ever been seen. 

Tubal Calculus simulating Tumour. — I have several times detected 
small gritty collections of deposit in inflamed tubes, and noticed that 
the grit often adheres firmly to the mucous membrane. If the deposit 
happen to lie near the fimbriae, the condition might be confused with 
the morbid appearances detected by Eve. The truth is, however, that 
such deposit is not cartilage, nor calcareous matter from a hypothetical 
degenerating fibroma of the tube. It is essentially calculous in nature. 
Dr. T. S. Cullen (9a), describes and figures an S-shaped calculus nearly 
an inch long which he found in an inflamed and obstructed tube. 

Myoma of the Tube. — Seeing that the tube is morphologically a 
part of the uterus, and that its walls contain dense layers of muscular 
tissue, it is perhaps remarkable that it is hard to find authentic cases of 
myoma. 

The uterus has thick walls, and the development of a myoma from a 
minute spherical body to its well-known advanced forms is familiar and 
easy to observe. With the tube it is different ; the walls are, in absolute 
measurement, thin. A tumour corresponding to the "interstitial fibroid'^ 



8oo SYSTEM OF GYNAECOLOGY 

of tlie uterus must soon spoil the tube by growing inwards and obliterat- 
ing the canal, or at least rendering it too much deformed to carry on its 
functions. On the other hand, it may, we can assume, be a "subperi- 
toneal fibroid " 5 in such a case its growth would not affect the tube so 
much. 

Most of the reported cases of myoma of the tube were pedunculated, 
that is, of the subperitoneal class. In any of these cases the tumour 
may have developed from the muscular fibres in the broad ligament at 
its point of reflexion over the tube, and not from the muscular coat of 
the tube. Sir J. Y. Simpson's case of fibroid tumour of the tube has 
been repeatedly quoted. It was "of a size equal to that of a child's 
head." On inspecting the well-known woodcut in his Clinical Lectures, 
it will be seen that the tumour, which was attached to the upper aspect 
of the tube by a pedicle several inches long, could hardly have arisen 
from the walls of the tube, which appear perfectly normal. It is easy 
to see how a myoma, developing in the broad ligament over the tube, 
would acquire a pedicle consisting of a part of the ligament itself, and 
stand out free from the tube. The same observation applies to the 
drawing in Keating and Coe's recent work, described as " fibro-myoma 
of tube (Museum of the College of Physicians and Surgeons)." The 
peduncle is of some length and breadth. No clinical history is given. 
Schwartz's case seems similar to Simpson's. At the operation a tumour 
" as big as an egg " was found connected by a pedicle, as thick as a fore- 
finger, and about one inch long, with the right tube, close to the uterine 
end. The pedicle was ligatured and divided. The tube itself is reported 
as normal, and was not removed. The uterus was free from any morbid 
sign. The patient was fifty-four, and the menopause had not occurred. 
It is hard to understand how a relatively large tumour, springing from 
relatively small structure like the tube, could have grown so free from 
the latter as to render removal possible without the sacrifice of the other- 
wise healthy structure. But further experience may prove that a myoma 
developed in the tubal wall does tend to grow outwards till it becomes 
more or less free from the parent structure, the sole ultimate connec- 
tion being a band of broad ligament. Such a change is quite different 
to what is so often seen in subperitoneal uterine myoma, and I doubt if 
it can ever be authenticated. In Spaeth's and Prochownik's case there 
was uniform hypertrophy of the muscular coat of the outer part of the 
tube rather than a true circumscribed tumour. The disease proved to be 
an oval mass two inches long ; the tubal canal passed an inch forward into 
its substance, ending in a blind extremity ; the ostium and fimbriae were 
effaced. The patient was thirty-nine years old. Bland Sutton reports a 
case where an interstitial myoma of the size of a Tangerine orange was 
found in the walls of a tube at the junction of the uterine and middle 
thirds. 

Lastly, many observers have mistaken collections of tuberculous 
matter and inflammatory changes in chronic salpingitis for minute 
myomas. In myoma of the uterus irregular hypertrophy of the 



DISEASES OF THE FALLOPIAN TUBES 8oi 

muscular coat of the tube is very frequent; Eeymoud has recently 
shown that this condition is associated with inflammation, hence he 
terms it '-'nodulo-follicular salpingitis,"' not "myoma of the tube." The 
follicular change is at least purely inflammatory. 

Cysts of the Tube. — The large irregular yellow bullae so often seen 
on the surface of the tube in cases of uterine myoma are not true cysts, 
but dilated lymphatics. When the adjacent tissues are divided during 
an operation the lymph drains away, and these bullse disappear. The 
common broad ligament cyst occasionally develops above the tube, or, 
more accurately speaking, under the serous coat at the free border of 
the tube. I have described a characteristic case elsewhere. 

The well-known pedunculated cysts which are so frequent near the 
fimbriae contain clear fluid and are lined with endothelium. The largest 
is the pyriform '• hydatid of Morgagni '' ; with its morphology and devel- 
opment we have nothing to do at present : it never forms a large cystic 
tumour, but I have seen it as large as a Williams pear. I find that it 
is very apt to undergo hypertrophy when the adjacent structures are 
diseased. In one case which I have examined its walls had undergone 
calcareous degeneration. The ovary was cystic, with twisted pedicle. 
In a case of attempted cure of an ovarian cyst, by drainage and sub- 
sequent removal of the cyst, I found that the hydatid of ^Morgagni was 
greatly hj-pertrophied ; its pedicle was six inches long, and a vessel of 
considerable size ramified on its surface. The cyst itself, though so 
elongated as to measure several inches, was narrow, so that it held but 
little fluid. Ott figures a ^'h^'datid" several times as large as the 
adjacent ovary, which was itself '"three times the normal size."" The 
" hydatid *' has connective-tissue walls with endothelial lining. There 
was chronic inflammatory disease of the corresponding appendages, and 
tubal pregnancy on the opposite side. Professor Sanger has recently 
described a most remarkable case, where two masses of cysts and solid 
growths sprang each from a pedicle which was evidently an abnormal 
fimbria. He has kindly permitted me to reproduce Dr. Earth's sketch 
of the specimen, taken when it was fresh. The uterus and opposite 
appendages were included in the sketch (Fig. 204) so as to display the 
relations of the tumour. The patient was twenty -six: after delivery 
an irregular tumour could be seen under the relaxed abdominal walls. 
Four months later it was removed as it had grown larger. The two 
fimbriae were simply ligatured with silk and divided. The left append- 
ages, whence the growths sprang, were replaced, being otherwise per- 
fectly normal, as were the right tube and ovary. The patient recovered 
and became pregnant again. The masses were of different colours — 
white, yellow or deep red. The more solid were made up of mucoid 
tissue, the cysts bore no epi- or endothelium, hence they probably repre- 
sented a degenerative change, mucoid tissue having broken down. They 
bore no relation to the '• hydatids " common in their neighbourhood. The 
entire growth was, Sanger believes, of congenital origin. 

Minute thin-walled cvsts are often seen on the surface of the tubal 

3f 



8o2 SYSTEM OF GYNECOLOGY 

mucous membrane within the ostium. Their precise pathological import 
has been much disputed. 

Dermoid Tumours of the Tube. — Thirty years ago Dr. Eitchie re- 
ported a case of tumour in a tube attached to a cystic ovary. The cyst 
was " as large as a plum ; it contained four loculi which were origi- 
nally filled with a creamy fluid. Each loculus was lined with a serous- 
looking membrane, studded at intervals with projecting dendritic growths 
absolutely similar to those so frequently met with in ovarian cysts. 
Besides this the tumour contained a plate of true bone, one and a half 



5x. 



/ 



\ 



/- 



!^' 





\ 

Fig. 204. — Cystic fibromyoma of the fimbriae (Sanger), a, &, Fimbriae forming pedicles to the cysts; 

c, ostium of the tube. 

inches long by about half an inch broad." I cannot find out what 
became of this specimen. Dr. Ritchie called it a dermoid cyst, but his 
description of its interior suggests papilloma and ossification. " Dendritic 
growths " are not often associated with dermoid cysts. Treub believes 
that a tumour which he removed from the tube was dermoid, but it 
is highly improbable that a dermoid tumour can develop in tubal 
tissue proper. On the other hand ovarian dermoids have strange 
peculiarities. I can well conceive how a tumour of that familiar class 
could contract very intimate adhesions to the tube so as to deceive the 
observer. Old pus and cheesy matter in the tube may also simulate the 
greasy material which fills many dermoids. 

In short there is no sound evidence that a dermoid tumour of the 
tube has ever been seen. 

Lipoma of the Tube. — I have detected true adipose tissue under 



DISEASES OF THE FALLOPIAN TUBES 803 

the mucous membrane of absolutely healthy tubes in young subjects. 
There would appear, then, to be no reason why a lipoma should not 
develop in the substance of the tube, even close to the uterus. On the 
other hand, it has long been known that a distinct layer of fat is some- 
times to be seen between the folds of the broad ligament just below the 
outermost part of the tube, following the ovarian fimbria. Eokitansky first 
recognised this condition. In 1889, in examining a dermoid ovarian cyst, 
I found a considerable amount of dense granular fat between the layers 
of the broad ligament (loe). In a sjjecimen of papillomatous ovarian cyst, 
which I remov^ed in 1894, 1 found an oval fatty tumour hanging by a dis- 
tinct pedicle from the Fallopian tube close to the root of the ovarian fim- 
bria (15?'). It measured barely half an inch in long diameter. It arose, I 
believe, from the broad ligament fat just described, or from an extension 
of that fat to the subserous tissue of the peritoneum covering the tube. 

Parona's case is of some importance : it is too often quoted at second 
hand. The patient was thirty-seven ; removal of the appendages for the 
relief of a uterine fibroid was undertaken. The left were low dowTi and 
their removal was difficult : the right ovary and tube bore the lipoma ; and 
as they lay high upon the myomatous uterus they were easily amputated. 
The lipoma weighed a little under 3 oz., and measured 3^ inches in long 
diameter. The ovary, " of normal size and texture," was attached to the 
tumour by a kind of pedicle formed of two layers of peritoneum which 
invested the lipoma ; the mesosalpinx, in fact, had been opened up. The 
fimbriated extremity of the tube showed clearly at one end ; the tube was 
partially sunken in the parenchyma of the tumour. On microscopical 
examination " traces of the wall of the tube with characteristic ciliated 
epithelium were seen mixed up with the adipose tissue of the lipoma." 
Parona's own words state that the tube " con adatte sezioni del tumore 
si tTOvb j^cirzkdmente sepolta nel parenchima del esso. Cio fii accertato 
con ripetute preparazioni microscopiche mediante le quali si rilevarono 
traccie di parete dell' ovidotto col caratteristico epitellio vibratile tramezzo 
al tessuto adiposo del lipoma." In an illustration the tube is shown laid 
open, winding on the surface of the lipoma in which its lower part only 
is "partially buried." The end of the original quotation just given 
might imply that the lipoma had really arisen in the substance of the 
tubal wall. If so, however, the upper or free border of the wall would 
surely have been invaded, so that the imbedding would be much more 
complete. I suspect that the fat arose in the folds of the broad liga- 
ment, as in my own case, and that it afterwards invaded the tube ; but 
even in that case Parona's expression "tramezzo al tessuto adiposo" 
does not explain whether an entire piece of tube, muscular coat, and 
epithelium was seen mixed up with the fat, or whether the histological 
elements of the tube, muscular fibres, and epithelial cells were actually 
scattered amid the fat cells of the tumour. 

Papilloma of the Fallopian Tube. — Much diversity of opinion still 
exists respecting papilloma and cancer of the tube. Only by a patient 
examination of existing records can we establish the diagnosis and pa- 




8o4 SYSTEM OF GYNECOLOGY 

thology of these important diseases. I therefore feel compelled to intro- 
duce the essential part of these records, trusting that my report will not 
be so brief as to be obscure, nor so long as to be wearisome. 

In 1879 I applied the term papilloma to an exuberant morbid growth 
which lay in the interior^ of a Fallopian tube. Several observers, 
especially in Germany (29a), agree with me as to nomenclature. That 
distinguished pathologist, Mr. Bland Sutton, on the other hand, classes 
such tumours under " adenoma." Here at once is matter for debate. 

In case 3 in the tables I detected patches of the disease in its earliest 
stages. It appeared as a small wart. The microscope showed (Fig. 205) 

that its structure was essentially papillomatous. 
The elevations are not glands, nor are they 
tubal folds. The section was made through 
a portion of the diseased tube, where the folds 
had long been effaced. The epithelium of the 
tubal mucosa, as I have already shown in the 
observations on salpingitis, is not necessarily 
shed, even after all the plicae are effaced 
^ „,,_ ,,. . , ,. ^ (Fig. 197, p. 787). When that change has 

Fig. 20o. — Microscopical section of ^^ 'J-. / . o 

a papillomatous outgrowth from occurrcd, as lu this and otlicr mstauccs of 
the left tube ^case 3) The papilloma of the tubc, there may, therefore, 

papillae are very fine, hke vilh, ^ ^ . . ' . -^ ' . ' 

and bear columnar epithelium ; remain plenty of epithelium to dcvclop iuto 
one papilla is branched. ^-^y^x which are esscutially epithelial growths. 

I made these researches in January 1888, and demonstrated sections 
at a meeting of the Pathological Society of London a month later. 
Next year appeared some perfectly independent investigations by Eberth 
and Kaltenbach (Tables, Carcinoma of Tube No. 3). In examining a 
tubal growth which proved, clinically at least, to be canceroas, they 
found that in its earliest stages it was made up of true papillae. As in 
my case (No. 3), the papillae appeared at first sight like villi. In parts 
the tubal mucosa looked like velvet, owing to collections of numerous 
long and short branched villi. At more healthy points on the mucosa 
there were evidences of incipient papillary growths. On microscopical 
examination the entire process of growth was found to correspond to the 
development of ridges of papillae on the skin. The increase of the stroma, 
or sub-epithelial connective tissue, was secondary, a fact which tallies 
with my own observations on No. 3 papilloma. This fact must be borne 
in mind when the opinion that the growth is adenoma, not papilloma, 
comes to be considered. Zweifel (Tables, Carcinoma No. 6), in 1892, 
noted that these growths in their earliest stage were villif orm ; more 
precisely they began as papillae, as is above explained. The question of 
cancerous degeneration will be discussed in the paragraphs on tubal 
carcinoma. 

When I applied the term " papilloma " to case 1, I had in my mind 
Hennig's observation, made three years earlier, that hyperplasia of the 

1 Papillomatous growths on the serous coat are not included in this class, which is con- 
fined to papilloma in the tube. 



DISEASES OF THE FALLOPIAN TUBES 805 

tubal mucous membrane passed into polypoid growth (as in some of the 
warts in No. 3) through the successive stages of warty and papillary 
tumours ; these transitional forms being often found side by side in 
dropsical tubes. I had already detected warty growths in a dilated and 
obstructed tube which, together with the adjacent ovary, had been sub- 
ject to long-standing inflammation. I believe that these papillomas are 
allied to the condylomas and Avarts seen on the external genitals irritated 
by venereal discharges. Doleris is of precisely the same opinion. In 
his case, No. 5, Tables of Papilloma, the patient had suffered from a 
venereal discharge. In No. 1 this complication may be discarded, but 
the history of pelvic inflammation was distinct. In all the six cases in 
the tables there is good reason to suspect that the disease was of inflam- 
matory origin, a sequel of salpingitis. Positive evidence is alone wanting 
in No. 4, Dr. Walter admitting that the earlier history of the patient's 
illness could not be determined. 

Mr. Bland Sutton's opinion that these growths are adenoma is based 
partly on the theory that true glandular structures exist in the tube, 
and partly on a painstaking re-examination of the growth in No. 1. 
That specimen, however, represented an advanced condition. I have 
already explained that the first stage in the development of a papilloma 
is represented by a villus or papilla, consisting chiefly of epithelium. 
The great increase of the stroma, which makes the tumour assume the 
appearance of a succulent adenoma, is late and quite secondary. Sanger 
and Earth make out two forms of the disease, " simple papilloma " and 
"cystic vesicular papilloma " ; No. 1 being of the second class : but both 
are held to be essentially papillomatous. 

The well-known solid intracystic ovarian growths are not inflamma- 
tory, but are glands which develop in the ovary just as hair and teeth may 
develop in that organ. Mr. Sutton and myself both believe it reasona- 
ble to consider adenomatous non-malignant ovarian cysts as allied to 
what is understood by the term " dermoids." In any case they are 
adenomas and not associated with inflammation. I cannot admit unre- 
servedly that papilloma of the ovary is identical with papilloma of the 
tube; clinically, at any rate, they are distinct, but, according to my 
observations, both diseases begin as papillae; hence both are papilloma. 
Whitridge Williams and, more emphatically. Professor Kossmann declare 
that papilloma of the ovary is not derived from parovarian relics as 
Coblenz, Sutton, and myself tend to believe, but from tubal elements 
{Nebentuhencysten, parasalpingeal cysts). At present all we have to bear 
in mind is that these observers admit that papilloma occurs in connection 
with the tube. 

Bland Sutton, like Hennig, believes in the presence of glands in 
the tube. His arguments will be fonnd in his well-known text-book. I 
myself was once inclined to accept the gland theory without hesitation. 
I cannot, however, overlook the fact that some of the most recent observers 
absolutely deny the existence of any structure corresponding to a gland 
in the Fallopian tube. Frommel, Whitridge Williams, M. Dixon Jones, 



8o6 SYSTEM OF GYNECOLOGY 

and, quite recently, Martin and Sanger in their text-book on Tubal Dis- 
eases issued in June 1895, are all more than sceptical about the exist- 
ence of glands. (See observations on Sanger's case of cancer of the tube, 
No. 8 in Cancer Tables.) Dr. Berry Hart, in the chapter on the Anatomy 
of the Female Genital Organs in this work, expresses the same doubts. 
All that I can say in relation to my subject, which is the nature of a cer- 
tain tumour, is that the scepticism about the presence of glands in the 
Fallopian tube prevents me from believing without hesitation that the 
tumour in question is an adenoma. The opinion of so distinguished 
an author as Bland Sutton must not, however, be set aside lightly. If 
he be correct adenoma of the tube may occur. Von Kecklinghausen 
denies that the tubal mucosa is furnished with normal glands, but he has 
detected, chiefly in tubes taken from the bodies of old Avomen who had 
died of pneumonia, and the like, remarkable glandular structures which 
he considers to be relics of the Wolffian body. They may be the source 
of Sutton's adenoma. 

The possibility of adenoma developing in the tube cannot affect the 
evidence which I and others have long since brought forward, that when 
seen at an early stage the tumour in question is always found to consist 
of a papilla or villus. Thus Fig. 205 could not be a morbid development 
from one of Bland Sutton's glandular diverticula. Therefore I shall 
retain the term ''papilloma." 

There are two features of high interest in association with papilloma 
of the tube. The disease is known to assume characters apparently 
malignant, though the after history, when the diseased part is removed, 
may prove the new growth to be innocent. It seems equally certain 
that if left alone the papilloma will undergo malignant degeneration. 
In the second place remarkable symptoms have been observed, as result 
of discharge from the growths in instances whefre the ostium or the 
uterine end has remained unobstructed. I have tabulated six cases 
which have been under close observation. In two (Nos. 1 and 4), the 
ostium was open and the peritoneum was full of fluid. In one (No. 5), 
the ostium was closed and the uterine end patent ; very free watery 
discharge escaped through the vagina in consequence. In two (N os. 2 
and 3), the tube was closed at both ends, and there was neither ascites 
nor discharge. No. 6 resembled Nos. 1 and 4, the ostium being open, 
but there was no ascites. 

No. 1 was a patient of Mr. Bickersteth's of Liverpool, and Sir Spencer 
Wells operated. I published the history, with a full pathological report 
in 1879, and issued notes of the after history seven years later. This is 
the case to which I referred at the beginning" of these observations on 
papilloma of the tube. The great feature of interest is the gloomy 
clinical aspect of the case before and during operation in 1879, as com- 
pared with the after history. For, in spite of ominous pleural and 
peritoneal effusions containing ugly-looking cells, and notwithstanding 
the presence of an exuberant new growth, and the impossibility of cutting 
through the Fallopian tube, at the operation, far beyond the limits of the 



DISEASES OF THE FALLOPIAN TUBES 807 

growth, no recurrence occurred. Schroeder in 1886 maintained that this 
case was evidently malignant. (See also observations on No. 3 in the 
Tables of Cancer*^ of the Tube.) On 14th :N^ovember 1895, Mr. Bicker- 

steth wrote to me saying, " Miss called on me a few days ago, and 

I never saw her looking better." 

The patient was first seen by Mr. Bickersteth in October 1877. She 
then had symptoms of inflammation of the right ovary following menor- 
rhagia, which subsided after rest. This history of inflammation must be 
borne in mind; it is common to all the cases of papilloma (except that in 
jSTo. 4 it was not noted), and the relation of this morbid growth to 
inflammation has already been discussed. The clinical and pathological 
relations of adenoma are different. In March 1878 the patient had an 
attack of pleural effusion on the right side; 120 ounces of clear fluid were 
removed by tapping. In July, 9 pints of fluid were drawn off from the 
abdomen, which had become swollen. In September, 13 pints were 
removed from the abdomen. In October, 100 ounces were drawn off on 
tapping the right pleura. In January 1879, the abdomen was tapped a 
third time and 16 pints were drawn off. These accumulations of fluid 
and the five tappings were not accompanied by rise of temperature or 
systematic disturbance. There were no signs of cardiac, hepatic, or renal 
disease. 

In March 1879, when the patient, a thin and emaciated maiden lady, 
was fifty years of age, Sir Spencer Wells first saw her. As she objected 
to an exploratory incision the abdomen was tapped for the fourth time, 
and 22 pints of fluid were removed. The specific gravity of the fluid 
was 1022, and it coagulated almost entirely under the action of heat and 
nitric acid. Its scanty flocculent deposit was found to consist of large 
cells, mostly grouped in clusters and apparently proliferating; many were 
distinctly vacuolated : similar cells had been found in the pleural fluid. 
I examined some of these cells, and never saw any structure in morbid 
fluids that more thoroughly suggested malignancy; and at that date I 
was examining ascitic and cystic fluids many times a Aveek. Since then 
I have ceased to trust the evidence of solitary cells in the diagnosis of 
malignancy. The incident of effusion will be considered in association 
with one of the conditions detected after the operation. 

The uterus was movable, and so low in the pelvis that the cervix lay 
close to the vulva ; behind that organ a hard nodular mass could be 
detected. On April 28, 1879, Sir Spencer Wells operated. The peri- 
toneal cavity contained 17 pints of amber-coloured fluid. A tumour 
of the size of a large orange lay to the right of the uterus ; it was 
removed together with the right ovary. ^N'o secondary deposits could 
be found on the peritoneum, notwithstanding the most careful search. 
Recovery was rapid. The patient suffered from an attack of pleurisy 
four months later without any effusion. Menstruation had ceased for 
over two months before operation; one tube and ovary, be it remembered, 
were not removed. As has been already observed, the patient was well 
in the autumn of 1895, sixteen years after the operation. 



8o8 



SYSTEM OF GYNECOLOGY 



The tumour, now in the Museum of theEoyal College of Surgeons (Path. 
Series, No. 4584) consists of the Fallopian tube, extremely dilated, with 
the ovary, unaffected, beneath it. The uterine end admitted a bristle which 
could be passed through the entire tube and out of the ostium. The fim- 
briae, short and thick, were still to be seen ; the ostium was abnormally 
patulous. Cauliflower excrescences sprouted from all parts of the mucous 
membrane; they were covered with a mucoid material which issued from 
the ostium. 




Fig. 206. — Papilloma of the Fallopian tube. Case 1. The tubal wall has been divided along' its tipper 
border and turned back, exposing the papillomatous masses springing from the mucous membrane. 
A bristle, entering the cut uterine end, passes along the tube amidst the growths, and emerges at 
&, the ostium. The tube is undilated as far as a ; c, ovary ; d, small pedunculated cyst; e, cyst 
developed amidst the papillomatous growths. 



Here I must pause to consider the pleural and peritoneal effusions in 
this non-malignant case. So far as innocent ovarian tumours are con- 
cerned, M. Demons of Bordeaux has published researches of great value. 
He has seen pleural effusion in 9 out of 50 cases of common ovarian 
cyst. One of his patients had an ovarian tumour on the right side and 
free effusion into both pleurae. Cancer was reasonably suspected, as in 
the case of tubal disease now under consideration. The pleura was 
tapped several times on both sides ; but the fluid rapidly re-accumulated 
and the health began to faih Demons did ovariotomy, the double 
effusion disappeared " like magic " and never returned. He attributes 



DISEASES OF THE FALLOPIAN TUBES 809 

the pleural effusion to lymphatic obstruction due to the interference of 
the tumour with the circulation in the abdominal lymphatics, which 
arrest extends through the diaphragm to the lymphatics of the pleura. 
In other cases Demons observed more or less abundant ascites. Verneuil 
believes in the lymphatic obstruction theory. 

In this case of papilloma the existence of lymphatic obstruction is 
hard, if not impossible, to detect. I found that free mucoid material 
issued from the ostium. As in this case 1 in the tables, so in case 4 
there was ascites ; in both the ostium was open. Hence it is reasonable 
to believe that some irritation from the discharge set up the effusion. 
The big cells indicated more than lymphatic obstruction. Lucas- 
Championniere, in the discussion on Demons' communication, stated 
that he found pleural effusion with or without ascites most frequent in 
cases of proliferating abdominal tumours. I have operated on free 
papilloma of the ovary, where abundant ascites existed, the effusion 
disappearing permanently afterwards ; hence, I fancy that the effusion 
is due to irritation of some sort. The papillomas in one of my cases 
seemed too small to obstruct anything. In the tubal case both the 
peritoneum and one pleural cavity suffered from this irritation, but as 
the phenomenon of abdominal tumour with pleural yet without peri- 
toneal effusion did not occur in this case, it need not be discussed here. 





^^^ ">^ 

Fig. 207. — Papilloma of the Fallopian tube. Case 1. Sections of an outgrowth under a high and a low- 
power. (I, Papilla, the same which is shown more highly magnified ; h, space lined with epithelium. 

I have minutely described elsewhere the microscopic appearances 
of this growth. A layer of columnar epithelium invested the whole of 
the outgrowths which made up the tumour. It was ciliated at certain 
points, and nowhere invaded the stroma. 

The arguments in support of my original opinion that the new 
growth was in this case a true papilloma rather than an adenoma, have 
been given at the beginning of these paragraphs on the subject. Sec- 
ondary increase of the stroma may fully account for the appearances 
in this tumour. It may account for the large cystic spaces lined with 
epithelium which I discovered in the stroma (Fig. 207, 5). The papillae 
developed, I believe, as a result of salpingitis. The spaces would in 
that case be identical with those which so often develop when the 



8io SYSTEM OF GYNECOLOGY 

tubal mucosa becomes inflamed ; the manner in which they form has 
been already explained (see p. 788, and Fig. 200). Bland Sutton com- 
pares the tumour-substance with the normal tubal mucosa in a macaque 
monkey. As there is still more stroma in the macaque's tube in 
health/ this resemblance would imply, not that the tumour was an 
adenoma, but rather that it was a pure hypertrophy. 

The clinical features of case 2 are sufficiently explained in the 
appended tables. I assisted at the operation, and plainly saw that it 
was a Fallopian tube that Avas removed. The ostium was closed. The 
cavity was stuffed with rather gritty papillomatous masses. Unfortu- 
nately this valuable specimen was accidentally lost. 

Case 3 is very suggestive. At the beginning of these observations 
I have noted that the new growth could be detected in its incipient 
form as a papilla (Fig. 205, p. 804). The ovaries and tubes had under- 
gone simultaneous cystic degeneration, the result of long-standing in- 
flammatory disease; and papilloma had begun to develop on their inner 
walls. I fully discussed these changes in the paper referred to in the 
tables, and I shall again refer to this case in speaking of Warnek's 
example of tubal cancer (No. 12, Tables of Cancer of Tube). 

The fourth case was originally recorded by Bland Sutton. Dr. Walter 
informs me that the patient did not recover from the operation. Mr. 
Sutton has given a description of the microscopical appearances of the 
growth, which he considers to be an adenoma. I must, however, dwell 
on one sentence in his observations ; namely, that " the specimen differed 
from Doran's case in that it contained a far larger proportion of stroma." 
Hence it may have been of older growth. As in No. 1, there is no evi- 
dence as to what the earliest appearances of the growth might have 
been. The ascites and patulous ostium cause No. 4 to resemble No. 1. 

In case 5 the patient was a public singer of irregular habits. There 
was a long history of vaginal discharge, attacks of pelvic inflammation, 
carelessness of advice, and immoderate sexual indulgence. In May 
1888, when straining at stool, a great quantity of sero-sanguineous fluid 
escaped from the vagina. The discharge continued for six days, often 
drenching the patient's clothes. Several quarts came away. A week 
later the period occurred and lasted six days, then the free discharge re- 
commenced. The pains, which had been severe, subsided. The abdomen 
was almost flat throughout. (Nos. 15 and 17 in the Cancer Tables pre- 
sented these remarkable symptoms of " hydrops profluens.") On ex- 
amination a swelling was found in each fornix ; serous .fluid was seen 
to issue freely from the os uteri. The tubes could not be catheterised. 
Eleven months after this examination, the serous discharge having 
become very free, M. Doleris operated. The left appendages were 
removed; they were much altered by chronic inflammation. On the 

1 Here we must be careful in verifying Mr. Sutton's researches, lest the tubes of 
quadrumana selected for examination as normal be really diseased. Monkeys in cap- 
tivity are very often sickly, their well-known sterility and still better known sexual 
irritability both lead us to suspect that disease of the genital tract must be frequent. 



DISEASES OF THE FALLOPIAN TUBES 8ii 

right side was a tumour adherent to intestine, omentum, and the pelvic 
wall. Its surface was pearly white. After removal it was found to 
consist of the right Fallopian tube. From its inner w^all grew masses 
of arborescent vegetations of the kind usually observed in papilloma. 
There was a central part of vascular connective tissue, and a layer of 
epithelium on the surface. At certain points these cells, which were 
cylindrical, were arranged in double or triple layers which the patholo- 
gists reported as suggesting malignancy. The ostium was closed, 
the uterine end remained relatively narrow, bearing no papillomatous 
growths, but the canal was patent and dilated. The operation was 
performed in July 1889. Doleris informed me, in a letter dated 23rd 
October 1894, that there had been no recurrence, and that the patient 
was in very good health. In a less marked case of intra-tubal papilloma 
in his practice the result had proved equally satisfactory. 

The remarkable symptom which was so prominent in this case is 
evidently identical with the '"'hydrops tubse profluens " cf old writers, 
though watery discharge may occur in simple hydrosalpinx. Indeed, 
case 1 was an instance of the same phenomenon, save that the fluid 
discharged itself into the peritoneal cavity and not externally. 

Case 6 fortunately came under the observation of a competent 
observer, Mr. Bland Sutton, who was also the operator. The patient 
had been subject to pelvic pain and menorrhagia for some time. " The 
right tube was enlarged to the size of a finger ; the ostium was open, 
the walls greatly thickened, and its interior stuffed with adenomatous 
masses in structure resembling those found in Doran's specimen (Xo. 1). 
There was no hydroperitoneum or watery discharges from the vagina." 
Thus Sutton's valuable report shows that in papilloma of the tube 
with patulous ostium peritoneal effusion is not always present. On the 
strength of his evidence I have refrained from generalising on this rare 
disease ; it shows, at least, that one important clinical symptom was 
absent in 1 out of 3 similar cases (Xos. 1, 4, and 6). The left tube in 
case 6 was strangulated by an adhesion between the ovary and intestine; 
it did not bear papillomas. The patient, Mr. Sutton kindly informs me, 
was living nearly four years after the operation. 

Since the above notes were prepared, Godart (19a) has described a 
case where abdominal section was performed for symptoms of pelvic 
inflammation in a woman aged 32. In a dilatation, as big as a walnut, 
in one tube, there was a papillomatous mass consisting of hypertrophied 
plicse. He looked upon it as a purel}' inflammatory condition, not a 
new growth, a distinction which I have already discussed. 

Treatment. — The clinical and pathological evidence above given in- 
dicates but one line of treatment, removal of the diseased tube. The 
ovary must be removed with it. The ligature should be tied close to 
the uterus, and if papillomatous growths are seen on the exposed mucosa 
of the stump they should be destroyed with the thermo-cautery. Prog- 
nosis must be guarded even after a successful operation. No doubt 
the after history in case 1 is most encouraging, but it will be seen that 



8i2 SYSTEM OF GYNECOLOGY 

the distinction between papilloma and cancer is not by any means 
easy. 

Cancer of the Fallopian Tubes. — There can be no doubt that the 
Fallopian tube may be the seat of primary cancer. Until a few years 
ago it was asserted in text-books that authors were agreed that cancer 
of the tube is always secondary. Since attention was first turned to the 
subject, cases of alleged primary cancer, not always indisputable, have 
been published from time to time by clinical and pathological observers. 

Those who speak of tubal cancer as always " secondary '^ are further 
incorrect in that they usually mean to imply simple extension of malig- 
nant disease from the uterus or ovary. A good instance of this extension 
of cancer from the uterus is described and figured in Sir John Williams' 
Harveian Lectures. Drs. Ballantyne and Williams record an interesting 
case of cancer of the tube, which they are inclined to consider as " sec- 
ondary/' in the true pathological signification of the term. Scanzoni's 
case is sometimes reported as primary tubal cancer. I believe that it 
began in the ovary, as that organ was " of the size of a fist," whilst the 
tube was only ''of the thickness of man's thumb." This proportion is 
reversed in No. 2 in the appended tables. Scanzoni observes that his 
case proves that cancer of the tubes does not always arise from the 
contiguity of those organs to diseased neighbouring structures. It seems 
likely that the tube was affected with true secondary cancer. 

In cancer of the ovaries the tubes, as a rule, are not involved till very 
late, if at all. I have repeatedly seen the tube quite healthy when the 
corresponding ovary had become a large sarcomatous or carcinomatous 
tumour. Schroeder and Ballantyne and Williams note this clinical fact. 
Sanger (41, Fig. 53) describes a case of cancer of the ovaries extending 
to the tubes, which remained quite small though distinctly infected. 
Extension of cancer from the uterus to the tube is not common. 

Since Dr. Orthmann described Dr. Martin's case (No. 1) over a dozen 
instances of primary cancer of the tube have been described.^ Two forms 
may be distinguished : in the first, carcinoma develops in the mucous 
membrane of a normally formed tube ; in the second it develops in a 
tube which is malformed, bearing a cyst (not connected with the ovary) 
into which the ostium opens. The cyst wall becomes infected. 

1. Primary Cancer of a normally developed Fallopian Tube. — In May 
1888, 1 stated at a meeting of the Pathological Society " that malignant 
disease of the tube may result from a degeneration of papillomata of the 
tubal mucous membrane." This remark was in reference to the specimen 
(case No. 2) which I then exhibited. Since that date this opinion has 
been confirmed by other writers who have examined other specimens. 
I have already shown that papilloma tends to degenerate into carcinoma 
(p. 806) ; I may now add that it is not easy to distinguish papilloma of 

1 Dr. Renaud of Manchester, in an Atlas of unpublished pathological drawings, now in 
the Library of the Museum of the College of Surgeons, figures a specimen of " medullary can- 
cer of the right and left oviduct, also of right and left ovaries." The date is November 1847. 
As fur as can be judged from a drawing the disease appeal's to have originated in the tubes 



DISEASES OF THE FALLOPIAN TUBES 813 

the tube from carcinoma. Landau and Rheinstein Q^q. 5) discuss the 
histology of those new growths very carefully. The column " Character 
of the Tumour " in the tables shows how frequently the supposed cancer 
was papillomatous, at least in appearance (N"os. 1, 3, 4, 6, 7, 8, 9, 10, 12, 
13, 14, 15). The distinction between ''villous" and papillomatous" 
must remain doubtful. The actual origin of these papillomas from 
papillae, described at page 804, must be carefully borne in mind when any 
case of cancer is considered. I have given reasons for believing that 
the morbid papillae develop on the mucosa of tubes subject to chronic 
inflammation.^ Hence, in the tubes, cancer seems to be a distant sequel 
of inflammation. The '' Chief Symptoms " colmiin in the Tables of 
Papilloma and Carcinoma tends to conflrm this theory. 

The appended tables are based on a more limited compilation which 
I prepared for my second report of case 2. It has been extended by Dr. 
Fearn and by Sanger and Barth. I here add fresh cases and additional 
information ^ respecting recurrence and other matters on cases already 
reported. For such information I must thank the gentlemen after whose 
names, in the " Reporter and Reference " column, I have added the 
words " private correspondence." These words will serve to explain 
how certain facts not in the original printed records came to be inserted 
in the tables. 

In case 1 there is a long history of pelvic inflammation, following an 
attack of typhoid fever one year and a half before operation ; but the 
inflammation may have arisen from abortion a little previous to the 
fever. The mucous membrane of the tube was covered with soft 
papillomatous growths filling the lumen of the abdominal end, where 
they were numerous. Each growth consisted of a stroma or connective 
tissue, including numerous nests of epithelial cells. Here and there 
involutions of epithelium were detected passing into the stroma.^ 

I was present at the operation upon No. 2, and made a minute 
examination of the diseased tube. I was also enabled to inspect the 
pelvic viscera after the patient's death from recurrence. The specimen 
is preserved in the Museum of the Royal College of Surgeons, No. 
4584 D. 

At the operation the infected ovary, much smaller than the diseased 
tube, was found strongly adherent to adjacent structures ; the examina- 
tion of the pelvic viscera ten months later showed that none or very 
little of the ovary was left behind, as the operator feared at the time. 
The uterus was quite healthy. The cancerous tube measured five inches 
in length when collapsed. It contained several drachms of ill-smelling, 
bloody serum with minute solid fragments. This fluid closely resembled 
the vaginal discharge which Dr. Amand Routh, who attended the case 

1 See especially the observations No. 3 in Tables of Papilloma of the Tube. 

2 Thus in Sanger and Earth's tables there is no note under Kaltenbaeh's case (No. 3 
in my tables) that recurrence took place. 

3 See the fine microscopic drawings in Orthmann's original paper (reference, No. 1 
iu tables) . 



8i4 



SYSTEM OF GYNECOLOGY 



before operation, had already observed. Abnost the entire mucous 
membrane was covered with a soft and highly villous growth of a bright 
red colour when fresh. No trace of ostium or fimbriae could be found. 
The ovary was almost spherical, and measured in its long diameter about 
one inch and three-quarters. jSTo normal ovarian tissue remained. 

The microscope showed that the new growth in the tube consisted of 
large polymorphous cells. They formed clusters bounded by trabeculse, 
in which the connective-tissue cells were undergoing proliferation 





y 




Fig. 208. — Primary cancer of Fallopian tube. Case 2. «, Uterine end of tube divided at the operation. 
A black bristle has been passed through it along the channel of the tube. /;, Portion of the tube 
near the uterine end free from growths; c, c, c, masses of cancerous growth springing from the 
inner surface of the tube ; d, new growtli invading the muscular coat, which is elsewhere mostly 
'free from disease ; /, ovary converted into a mass of tumour substance ; g, cut surface of broad 
hgament, which is infiltrated with new growth. 



(Fig. 209). In the deeper parts I noted some well-formed tubules lined 
with perfect columnar ciliated epithelium and surrounded by a wide area 
of large cells. The precise significance of these tubules is not at first 
sight clear. Senger, in his case of sarcoma (No. 1, Sarcoma Tables), 
detected tubes lined with cylindrical epithelium in the tumour substance, 
and traced them, as Von Recklinghausen would do, to the parovarium. 
Sanger in commenting on Senger's case, insists that such " tubes are 
not glands, as Senger maintains, but simply outrunners from normal plicae 
or from papillomatous growths. Eberth and Kaltenbach have already 
noted these false tubes. Hence these " tubules " are possibly homologous 
to the " cysts " lined with epithelium, on which I dwelt in my observations 



b — 




Fia. 209. — Primary cancer of Fallopian tube. 

Section of cancerous growth invading the wall of the tube (| inch objectiveV a, a. Larg'e poly- 
morphous cells ; h. part of a trabecula. bounding the group of cells, showing small cell infiltration : 
c, c. c, muscle-cells indicating remains of the muscular coat of tube. 

. Tubule-like structure a, seen in cancerous growth (see text). It is lined "s^ith cylindrical ciliated 
epithelium. Large cells, ?>, 6, surround the tubules ; they are arranged somewhat spirally, and 
prolonged outwards into the stroma at c, c. Farther on, at d, are larger cells. 

815 



8i6 SYSTEM OF GYNECOLOGY 

on salpingitis. Possibly again, the tnbules may be Wolffian relics, such 
as Von Recklinghausen has recently described. Fabricius (17a) believes 
in involutions and outrunners from the tubal mucosa. He has traced 
them to the serous coat. In short, there are several probable explanations 
of the origin of the tubules in Eig. 209, but it is not clear which is correct. 

The ovary seemed to be made up of the collections of large cells 
bounded by trabeculse as in the tubal growth. The disease seems 
clearly to have originated in the tube, where it was more advanced than 
in the ovary. The clinical symptoms before operation all indicated not 
ovarian tumour, but tubal disease. 

The patient died from recurrence nearly eleven months after the 
operation. Dr. Amand Routh kindly brought me the pelvic viscera for 
inspection, and I published my report. The surface of the cervical ca- 
nal and the endometrium bore numerous slightly elevated white spots 
representing secondary deposit; otherwise the uterus, though rather 
bulky, was normal. A spherical mass of cancer, not one inch in diameter, 
lay to the right of the cervix in Douglas' pouch, in a situation corre- 
sponding to the point of adhesion of the diseased ovary. 

No. 3 shows how difficult it is to distinguish a malignant papillary 
carcinoma from an innocent papilloma of the tube. I have shown how 
No. 1, in the Tables of Papilloma, looked very malignant, yet proved 
innocent. The present case was described by Professor Kaltenbach in 
a society report as " primary bilateral tubal cancer." Shortly afterwards 
I published the sequel or post-mortem report of case 2. I stated that 
Kaltenbach's case appeared " to represent simultaneous cancerous de- 
generation of papillomatous tubes." A few months later the deceased 
professor, in conjunction Avith Dr. Eberth, issued a complete report of 
the pathological appearances of the tubes. They traced the growth 
from its beginning as papillae springing from the mucosa, as I did, in the 
case of No. 3, Tables of Papilloma, at the very same time. These 
" independent researches " are discussed at page 804. They went farther, 
and declared that they could in no part of the growth detect any invasion 
of the stroma of the papillae by the epithelium, that is to say, any true 
cancerous process. 

Unfortunately the disease recurred after this careful report was 
published. In reply to inquiries. Professor von Herff, Kaltenbach's 
successor, informed me last year that the patient was readmitted into 
hospital, and extensive recurrence was detected. " She could hardly have 
lived much longer, but I could not obtain further information." (See 
Tables, No. 3.) Either Kaltenbach overlooked an area of cancerous 
degeneration, and thus failed to include it in his microscopic sections, 
or more probably, some papillomatous tissue, left behind after operation, 
became malignant. 

Sanger and Barth observe in their work that Eberth and Kalten- 
bach considered that the tumour in question was malignant, and that 
" Doran classes it without further discussion under Cancer " ; at pages 
265, 266 they still write doubtfully as to the malignancy of the same 



DISEASES OF THE FALLOPIAN TUBES 817 

tumour. But in their tables, under the heading " Eesult of Operation," 
I find, " Still quite well three-quarters of a year later." It is fortunate 
that I applied to Professor von Herff ; the consequence is that I have 
added, under the same heading, " Eecurrence within eighteen months," — 
most important evidence in relation to the malignancy question. 

On the other hand, No. 4 was described as " a case of carcinoma of 
the tube," at a meeting of the Berlin Obstetrical Society, 14th December 
1888. Professor Veit removed it in September of that year. There 
was pyosalpinx ; the inner surface of the tube was studded with abundant 
small growths, and microscopic examination of the latter plainly demon- 
strated carcinoma. Professor Veit, however, informs me that the patient 
was free from recurrence and in excellent health seven years later. 
Hence either the papillomatous growths w^ere malignant in appearance 
only, or else the distinguished professor extirpated a cancer very 
thoroughly. 

ISTo. 5 is the subject of an excellent monograph, where the opinions 
of Kaltenbach and myself on papilloma are impartially considered. 
Landau and Khein stein, the authors, are, however, too sanguine when 
they infer that papillomatous growths in the tube are " not to be 
reckoned amongst malignant tumours." They rely on an observation 
of their own and on the history of my own cases (i^os. 1 and 3, Tables 
of Papilloma). No. 3 in the Cancer Table, however, proves that a 
papilloma of the tube is always suspicious. Landau's case appeared to 
be an instance of medullary cancer ; he gives a good drawing of a section. 
As in case 2 the disease was advanced; it most likely represented a 
growth originally papillomatous. Recurrence was less rapid than might 
have been expected in so clearly malignant a growth. 

No. 6 was carefully examined by Professor Zweifel. At first sight 
sections viewed under the microscope seemed to indicate sarcoma ; but 
the cells with very large nuclei, w^hich lay in groups in alveoli amidst the 
stroma, were traced to the epithelium of the tube. Zweifel comments on 
the great resemblance between the new growth in his case and that 
Avhich I described as No. 1 in the Tables of Papilloma. The latter would 
have had the fate of the former, we may fairlj^ assume, had operation 
been delayed. Zweifel, less fortunate than Spencer AVells, had the dis- 
advantage of operating w^hen the disease was advanced and bilateral. 

No. 7 has frequently been quoted from second-hand sources, the 
original record being published in a Scandinavian medical serial. The 
authors give excellent reasons for believing that the morbid growth was 
a papillomatous cancer; they maintain that the infection of the right 
ovary was secondary, quoting my observations concerning infection of 
the tube in primary ovarian cancer (see p. 812). 

Professor Sanger removed a papillary cancer of the right tube " as 
big as a goose's egg " (No. 8). The patient was forty-five; and, as in 
Thornton's case, there w^as a history of menorrhagia. The uterus was 
dilated and explored, but found to be free from any new growth. Shortly 
afterwards abdominal section was performed, and the right tube was found 

3g 



SYSTEM OF GYNECOLOGY 



occluded at its abdominal end and cancerous ; but between the infected 
part and the uterus was an inch and a half of tube free from cancer, but 
subject to chronic inflammation. The growth seems to have advanced 
slowly ; and Professor Sanger considered it to be a papilloma which had 
undergone malignant degeneration. The patient was in good health and 
free from recurrence seven months after the operation. The operator 
has published a complete report of this case, with good microscopic 
drawings. His opinions on the papillary origin of the growth are in 
accordance with my own ; and in this case there was a history of old 
inflammation, which may indicate that the papilloma was a product of 
inflammation. As for the appearances of the malignant changes in 
the growth in case 8, he admits that they reminded him strongly of 
malignant adenoma of the uterus and papillary adeno-carcinoma of the 
ovary (yloc. cit. p. 257) ; but he cannot consider that the growth ISTo. 8 is 
homologous to uterine and ovarian tumours of the varieties just noted, 
as he is by no means certain that gland-like structures are to be found in 
the tube. 

No. 9 is excellently described by Dr. Fearn. His microscopic re- 
searches support my views that papilloma of the tube is truly papilloma- 
tous from the first ; that this growth tends to develop in tubes subject 
to chronic inflammation, and that, as m ISTo. 9, it may undergo malignant 
degeneration. According to his drawing of the diseased tube, it looks 
very like that in No. 2 (see Fig. 206). Though he describes the growth as 
"heteroplastic throughout," the patient. Professor Leopold informs me, 
showed no sign of recurrence a year and seven months after the operation. 

In No. 10 it is to be regretted that no note was made of the 
condition of the right ovary. The sequel, however, showed that the 
ovary could not have been cancerous, as the patient, MM. Tuffier 
and Hartmann inform me, was free from recurrence a year after the 
operation. 

Case 11 occurred in Dr. Cullingworth's practice, and has been fully 
described. In October 1894 the operator and Mr. Shattock kindly 
allowed me to examine the specimen. 

The tube measured a little under three inches. It was shaped like a 
gherkin, with a large prominence (Fig. 210, a) externally. Its walls 
were very thick ; the lumen wide for the first two inches, then lost, so 
that it was uncertain whether it went into the prominence a, or ended 
near h. No trace of a fimbriated extremity could be seen. The inner 
wall was very irregular, and at points (c, c) there seemed to be a smooth 
membrane over the new growth in the walls. This new growth was 
spongy on section, exposing irregular cavities ; minute papillary growths 
sprouted inside these cavities. Mr. Shattock compared this intra-tubal 
cystic growth to what is seen in duct-cancer of the breast. The meso- 
salpinx was opened up, so that the tube lay on the ovary, which was 
converted into a cyst. On the surface of this cyst were some small 
papillary masses similar to the growths in the tubes. 

Under the microscope the sponge-like tissue showed spaces with 



DISEASES OF THE FALLOPIAN TUBES 



819 



projections of tlie character of villi. Groups of cylindrical epithelial 
processes were detected in the connective tissue matrix. These processes 
acquired a lumen, which grew larger till the cystic appearance was 
developed. Mr. Shattock has minutely described these characters else- 
where. It is clear that the tubal growths and the secondary deposits on 
the ovarian cyst were carcinomatous. 

Warnek, a Russian authority, describes No. 12, the details of which 
are sufficiently explained in the tables. The pedicles of both diseased 
tubes were twisted. The malignancy of the growths was determined 
by Dr. Nikiforoff, Professor of Pathological Anatomy in the University 
of Moscow. Two features of particular interest are to be noted in 
Ko. 12. There was a tubo-ovarian cyst on the right side. The papilloma- 




> 'j>> ' -/^J' "^-^ -*^ '-'' 



^---.r^ 



'^^^, 



Fig. 210. —Dr. Cullingworth's case of primary cancer of the tube. It 
the cystic ovary. For lettering see text. 



;n Iving on the surface of 



tons masses in the left tube were pedunculated. These facts associate 
the case with ISTo. 3 in the papilloma series, Avhere tubo-ovarian cyst was 
in course of development ; though the cavities of the tube and ovary, 
both cystic, did not as yet communicate. In that case some of the 
papillomas were pedunculated. In other words, No. 3 Papilloma Tables 
seems to represent an early stage of the condition seen in Warnek's case. 
No. 13 Avill shortly be reported in full ; it is said to be a genuine 
example of primary cancer. No. 14 is a case where tubo-ovarian cyst 
seems to have existed. The right tube was dilated, and opened into a 
large cyst which contained over 17 pints of dirty brown fluid with 
sloughy shreds. This cyst, let it be remembered, could not be com- 
pletely removed, and the limits of tube and ovary do not seem certain. 
It may be homologous to Warnek's case (No. 12), and thus represent a 
malignant degeneration of the condition seen in No. 3 Papilloma Tables. 



820 SYSTEM OF GYNAECOLOGY 

On the other hand, the cyst into which the tube opened may have been 
independent of the ovary, as in Essex Wynter's case which will be 
described under a special heading. 

No. 15, which is published in full in Pean's work, issued in the 
summer of 1895, bears a certain resemblance to No. 2. There was 
sanious discharge for some time. A special feature was the disappearance 
and reappearance of the hypogastric tumour. " Hydrosalpinx profiuens " 
was diagnosed. The case, in fact, seems a malignant form of No. 5 
(Doleris) in the Papilloma Tables. M. Pean is, I find, very sceptical 
about the primary character of tubal cancer. I have already shown, how- 
ever, how that the tube is subject to papilloma, and how the papilloma 
may become cancerous, — facts favouring the probability of primary can- 
cer of the tube. Moreover, Pean seems to believe in case 15, where there 
was clearly a true cancerous degeneration of tubal papilloma. 

A few more cases of primary cancer of the normal Fallopian tube 
have been reported, but less fully than those already described. Dr. 
Smyly, of Dublin, relates that '' I operated upon one case of cancer of 
the tube, supposing it to be an inflammatory condition. The operation 
was exceedingly difficult, and the rectum was opened in two places. 
These I closed by suture ; but the patient died of collapse. The true 
nature of the case was revealed by the microscope." Dr. Smyly informs 
me that, unfortunately, the report of the case has been lost. At the time 
of the operation he had no idea that he " was dealing with a case of 
malignant disease. The tissue was very friable, though not more than 
in many inflammatory cases. The uterus appeared normal and the tube 
and ovary on the opposite side were free from disease. The specimen 
was examined by Dr. Earl, a very competent pathologist and assistant 
to the Professor of Physiology in Dublin University. He reported it 
as undoubtedly cancer. Had I suspected this I should certainly have 
examined the uterus, but, unfortunately, the woman was buried before 
I received his report. There was no cancer anywhere else so far as I 
could see at the operation." 

Professor Zweifel recorded a second case of primary cancer of the 
tube in 1894. As in Dr. Cullingworth's case, it was associated with 
an ovarian cyst ; and the diseased part corresponded in naked-eye ap- 
pearances with the cancerous tube in case 6. Dr. Westermark sent me 
the following important piece of information in January 1895 : " I prom- 
ised, in my paper, a future description of a new case of cancer of the 
tube, but at the last research this case showed itself to be a cancroid 
developed in the ovary (probably arising from a dermoid), which had 
grown into the tube. In July last I operated on another case of primary 
cancer of the tube, but as the pathological research is not finished, I am 
unable at present to give any further description." Sanger, in his tables, 
adds the name of Mischnoff, but all that is said of the case is, " Not 
certain." 

2. Primary Cancer partly in a Cyst connected with the Ostium. — A second 
form of primary cancer of the tube has been noted by two observers, and 



DISEASES OF THE FALLOPIAN TUBES 821 

I have been kindly permitted to examine ttie first case. The patholog;y^ 
of this form is somewhat obscure. The tube is malformed, its ostium 
opening into a distinct cyst.^ This cyst is unconnected with the ovary. 
Zedel has already described and figured the anomaly in tubes where 
there was no suspicion of cancer. 

Essex Wynter and Koutier have reported these remarkable, though 
somewhat obscure cases. I am much indebted to Dr. Wynter and Dr. 
Voelcker for assistance in a thorough investigation of the case, which 
is briefly reported as a " Card Specimen " in the transactions of the 
Pathological Society. 

The principal features are recorded in the tables (No. 16). The 
patient had menstruated regularly since the age of sixteen, she was well- 
nourished, but complained of loss of strength, having been stout. The 
nature of the disease was doubtful during life ; her memory had failed 
considerably. Three days before her death pain began in the hypo- 
gastric region, and there had been vomiting in the morning. She 
became delirious, without fever, and died in the Middlesex Hospital 
about one month after admission. 

There were caseous, tubercular deposits at the apices of both lungs. 
The liver was small and fatty ; the kidneys fibrocystic. Other organs 
were normal, and there was no new growth in them or in the lymphatic 
glands. There was no ascites, and with the exception of a few intestinal 
adhesions to the tumour, the abdominal viscera were healthy. A cyst 
of the size of an ostrich's q%% was attached to the right tube, with which 
it was continuous. This cyst contained 8 oz. of brownish fluid. It had 
ruptured and leaked ; but, in Dr. Wynter's opinion, not till after death. 
There was no sign of peritonitis. 

Such is the report. The exact cause of death remains obscure. 
The absence of any new growth beyond the limits of the tube and its 
abnormal cystic appendage remains certain. 

I examined the specimen myself in October 1894. The appearances 
are indicated in Fig. 211. 

The right tube measured 4 inches in length. The corresponding- 
ovary (Fig. 211, c?), \\ inches in its longest measurement, was atrophied, 
elongated, and very thin. The ovarian ligament was abnormally long. 
The outer end of the ovary tailed off on to the surface of the cyst, from 
which that organ was otherwise quite distinct. 

The first inch of the right tube was relatively narrow, and united to 
the elongated ovarian ligament by membranous perimetritic bands. The 
second inch and a half was dilated and very tortuous, and over an inch 
in diameter in its widest part. The remaining and outermost part of 
the tube was yet more dilated, forming a spherical cyst over an inch in 
diameter ; in its wall was a solid deposit over a quarter of an inch in 
thickness (a). This outer portion communicated by an opening (6) with 

1 Dr. Martin's case, No. 1, may be of this kind ; the ostium of the cancerous right tube 
opened into a cavity full of pus. As, however, there was suppuration of the left tube and 
ovary, the cavity most likely represented an abscess. 



822 



SYSTEM OF GYNECOLOGY 



a thin-walled cyst (c). This cyst was quite free from the bladder, and 
measured six inches in diameter, before removal at the necropsy ; the 
anterior part had burrowed under and lifted up the anterior fold of 
the corresponding broad ligament, raising the serous coat of the uterus 
and the innermost part of the anterior fold of the left broad ligament. 
These relations are not indicated in Fig. 211, which was taken after the 
peritoneum had been displaced during dissection. The interior of the 
cyst contained, in parts, a thick deposit which appeared encephaloid in 
character. 

The left appendages were free from the cyst. The tube (e) was four 



/ 



a 



--^ 




i 




\ 



Fig. 211. — Dr. Essex Wynter's case of cancer of the tube. The uterine cavity ((7) has been laid open. 
The uterus was closely adherent to the cyst (c), but did not communicate with its cavity. The 
rent in the right mesosalpinx was made after death. The view is anterior. 

inches long, the infundibulum somewhat dilated, the ostium open. The 
left ovary (/), hardly an inch long, was atrophied ; the ovarian liga- 
ment, very thick, measured an inch and a half. 

I examined with. Dr. Voelcker some microscopical sections taken 
from the deposit in the dilated extremity of the right tube. The stroma 
was scanty and formed wide alveoli containing cubical epithelium. In 
parts these cells were collected in great masses, as in encephaloid cancer. 

All evidence seems to indicate that the tube was the primary seat 
of cancer, the disease extending to the abnormal cyst connected with 
the ostium. No. 17, M. Eoutier's case, resembled Wynter's in many 
respects. On the high authority of Professor Cornil, the growth was 



DISEASES OF THE FALLOPIAN TUBES 823 

pronounced to be " primary epithelioma of tlie tube." Cornil further 
considered that the cyst was connected with the tube, and was not 
ovarian; we must not forget, however, that the corresponding ovary 
could not be found at the operation. Hence the cancer may have 
developed in a true tubo-ovarian cyst. Eighteen months before the 
operation sharp pain was felt in the left iliac region, suddenly "an 
enormous quantity of lemon-coloured fluid " escaped from the vagina. 
The pain lessened and the tumour became at once much smaller. This 
escape of fluid reminds us of case 5 in the papilloma series, and case 
15 in the Tables of Cancer. The etiology is quite different, but the 
pathology may be similar, the discharge coming from papillomas which 
ultimately became cancerous. 

General Considerations on Cancer of the Tube. — The above records 
amply prove that cancer of the tube is not an unknown disease, and that 
it may certainly be primary. No doubt some of the reporters of the 
sixteen cases which are included in the Cancer Tables may have been 
mistaken, A primary seat of malignant disease, more or less distant 
from the tube, may have been overlooked. The tumour may in one or 
more cases have been sarcomatous, not cancerous. In one or more cases 
an innocent papilloma may have been recorded as malignant. Never- 
theless the majority of the cases were cancerous. The cancer in nearly 
every tube assumed a villous or papillomatous appearance ; the exceptions 
are doubtful, as the disease may have lost a papillomatous character 
which it originally possessed. The origin of papilloma may usually be 
traced to inflammatory changes. Hence cancer is a remote result of 
salpingitis ; or perhaps it is safer to say, cancer is specially apt to attack 
tubes long subject to inflammation. 

Clinically, at least, the early history of tubal cancer nearly always 
suggests tubal inflammation. The disease is unknown in youth. Out of 
the seventeen cases in the Cancer Tables only one was in a patient so 
young as thirty-six ; and in this instance (No. 4) the after history indicated 
a very low degree of malignancy. Another patient Vv^as forty -three. All 
the remaining fifteen patients had passed their forty-fifth year. 

When a patient who has reached her forty-fifth year, and has been 
subject to pelvic inflammation, shows a sudden or steady aggravation of 
subjective and objective symptoms, cancer may be suspected. A watery 
or especially a sanious discharge in such a case greatly increases the 
probability of malignancy. 

Treatment. — If, as has been shown, removal of the tube is necessary in 
papilloma, it is all the more urgent in cancer. Out of the seventeen 
cases in the tables, sixteen underwent operation; two died of the direct 
effects of the operation ; five lived over one year ; four died within a year ; 
whilst in five the after history is incomplete — one (No. 14) being convales- 
cent when reported; one (No. 13) died of "marasmus" at an uncertain 
date ; one (No. 15) was in good health eight months later, but the tumour 
had recurred ; one (No. 8) was still alive and well seven months after opera- 
tion, whilst the fifth (No. 1^) never reported herself after convalescence. 



824 SYSTEM OF GYNECOLOGY 

For cancer the above record is by no means gloomy. Even when 
recurrence was comparatively rapid the patients seem to have enjoyed a 
few months of comfort. This was certainly the case in No. 2, which was 
under my own observation.^ 

Sarcoma of the Fallopian Tube. — In primary sarcoma of the ovary, a 
well-recognised and not very rare disease, the tube is seldom implicated. 
I have examined enormous sarcomas of the ovary where the tube re- 
mained intact. On the other hand, in a few cases I have seen sarcoma- 
tous nodules scattered over the peritoneal covering of the tube. The 
new growth more frequently passes from the ovary to the omentum, and 
to the serous investment of the intestines, uterus, and abdominal walls. 

Few can deny that in all or nearly all the cases of alleged primary 
cancer of the tube the new growths were carcinoma, at any rate, if 
not primary. Thoughtful observers have expressed doubts whether the 
recorded cases of primary sarcoma of the tube do not demand a different 
interpretation. The growths, they believe, are not evidently sarcoma 
or even true neoplasms. The close relations of papilloma of the tube to 
carcinoma, and the tendency of the former to degenerate into the latter, 
have already been noted. When the stroma of a papilloma becomes 
abundant it may possibly undergo sarcomatous degeneration. Some of 
the cases in the tables may represent this change, which is certainly rarer 
than cancerous degeneration. 

Much confusion exists in relation to the first recorded case, as the 
name of the original observer is Dr. Senger, which is often misspelt 
" Sanger," whilst another case has been reported by Professor Sanger 
himself. In this case (No. 1, Sarcoma Tables) papillomatous masses, con- 
sisting of small-celled, round-celled sarcomatous tissue were found growing 
from the tubal mucous membrane, chiefly in two oval dilatations of the 
tube. In one of these dilatations there was a polypoid growth contain- 
ing collections of tubules lined with cylindrical epithelium, and surrounded 
partly by true sarcomatous tissue, partly by new connective tissue rich in 
nuclei. Dr. Senger believes that these tubules were derived from the 
parovarium ; an opinion in accordance with Von E,ecklinghausen's new 
hypothesis quoted above (p. 806). The tubules suggest the appearances 
which I detected in the tube from case 2, Cancer Tables — an instance 
of cancer, not sarcoma, whatever the tubules may have been. I find that 
Sanger and Barth are of the same opinion. Dr. Coe of New York gives 
a different interpretation to this morbid appearance. He believes that 
the whole growth was no neoplasm, but chronic inflammatory deposit. 
He has observed a similar condition in many tubes removed for chronic 
inflammatory disease. The tubules were, he considers, simply gland-like 
depressions in the mucous membrane developed by the folding-in of the 
hypertrophied mucosa. I noted this condition in my description of No. 2 
(Cancer Tables), but observed that it was also seen in papilloma. The 
history of the case may seem to favour Dr. Coe's view that the tube was 

1 1 add in the Cancer Tables two cases (15a and 17a) of considerable interest, published 
since the above lines were written. 



DISEASES OF THE FALLOPIAN TUBES 825 

the seat, not of a tumour, but of old and quiescent inflammatory disease. 
Dr. Coe, however, must not overlook the fact that a similar history is 
the rule in cases of tubal cancer. The presence of a secondary deposit 
in Douglas' pouch makes me incline rather to the theory that the morbid 
deposits were new growths. Sanger (who also dwells on the secondary 
deposit) considers that Senger's case pathologically resembled his own 
(No. 4, Sarcoma Tables). 

In case 2 there was a blood-cyst as big as an apple "between the 
sacrum and right ovary, adjacent to a tumour of the size of a walnut " 
developed in the abdominal portion of the right tube, the lumen of which 
was pervious. This tumour, on the high authority of Professor Landau, 
was a small-celled, spindle-celled sarcoma. No relation between the 
blood-cyst and the sarcoma is suggested,^ nor any reference made to tubal 
pregnancy ; the latter subject will be discussed in respect to Dr. Charles 
Dixon-Jones' cases. 

Case 3 must remain doubtful. Dr. Janvrin's original report is 
excellent. Unfortunately, as in case 2, the patient died a few days 
after the operation, so that we cannot tell whether recurrence could 
have occurred had either patient recovered. The pathologist. Dr. 
Porter, does not speak very decidedly about Janvrin's tumour. •' The 
general histological construction of this newly developed tissue would 
argue against its being classed as an inflammatory growth, but would 
place it among the mixed connective-tissue growths. Owing to the large 
variety of histological elements found, it is impossible to give it any 
single name which will in any adequate manner express the condition. 
It may well be classed under one of two headings, either as a composite 
fibro-sarcoma, or a coinposite myxo-sarcoma, the latter being the more 
accurate of the two." The photogravure appended to Janvrin's paper 
and the clinical report alike suggest that the tube was the seat of chronic 
inflammatory changes. Such changes, on the other hand, are sometimes 
followed by malignant tubal disease, as I have already shown. 

The fourth case. Dr. Sanger's, is the least doubtful, for the patient 
recovered from the operation; but the mischief recurred and proved 
fatal. The microscopical report comes from a very trustworthy quarter. 
Professor Sanger calls the tumour " essentially a small-celled, round- 
celled sarcoma." There was a broad ligament cyst on the left side. 

A remarkable paper was recently written by Dr. Charles Dixon-Jones, 
who quotes freely from Dr. Janvrin's report of case 3, accepting, it is 
clear, the opinion that it was an instance of sarcoma and not inflam- 
mation. Dixon-Jones received from Professor Pormad of Philadelphia, 
thirty-five specimens of tubal tumours all believed to be cases of tubal 
pregnancy removed after death from women who had died suddenly. 
They were selected specimens from the necropsies of over 3000 adult 
women. Many of the thirty-five were decomposed. Of those found 
fit for microscopic section three proved, in Dixon-Jones' opinion, to be 

1 Both tumours might have been sarcoma originally. See Godlee, " Blood-cyst 
developed in a Sarcoma. Trans. Path. Soc. vol. xxvi. p. 193. 



826 SYSTEM OF GYNECOLOGY 

malignant tumours of the tube-wall, and not tubal pregnancies. Intra- 
peritoneal haemorrhage is assumed as the cause of the sudden death in 
all the thirty-five cases. In the three supposed malignant cases there 
certainly was evidence of rupture of the tubal wall and hsemorrhagic 
infarction into the substance of the new growth. The large vessels 
involved in the sarcoma tissue seem to have yielded. Dixon-Jones 
describes the three specimens as (1) " globo-myeloma (large round-celled 
sarcoma) " ; (2) " spindle myeloma (large spindle-celled sarcoma of 
Virchow) " ; (3) " melanotic myeloma (melanotic sarcoma of Virchow)." 

No pathologist could accept unconditionally the opinion that these 
morbid specimens were really sarcomas. The clinical histories are hypo- 
thetical. The alleged discovery, in so limited a number of specimens, of 
three cases of a rare disease, the very existence of which is still disputed, 
is in itself suspicious. Where else do we hear of a case of sudden 
death from rupture of a sarcomatous tube ? Old inflammatory deposits 
mixed with blood-clot and relics of tubal gestation may readily deceive 
the pathologist. 

Finally, it is clear that primary sarcoma of the tube as a disease is 
very rare, and as a subject highly obscure. The evidence of Sanger and 
Landau establishes the fact that a tumour of this pathological class may 
involve the mucous membrane. Senger's case seems to support this 
evidence. Janvrin's shows that sarcoma may be confined, or almost con- 
fined, to the deeper part of the tubal wall. Sanger seems inclined on 
that account to place that case (No. 3) in a distinct sub-class. We have 
not sufficient evidence, however, to prove that sarcoma does not always 
arise in the interior of the tubal wall, as the pathologist would naturally 
expect. In 2 and 4, where the mucosa was involved, the disease was 
advanced. The difficulty of distinguishing between new growths and 
inflammatory deposit greatly complicates the sarcoma question on account 
of the well-established frequency of true inflammatory changes preceding 
the development of a true neoplasm. Nothing can be decided until more 
clinical evidence is at our disposal. In the meantime there can be no 
doubt that the timely removal of a suspected sarcoma of the tube is 
justifiable. 

Deciduoma Malignum of the Tube. — Two cases of this remarkable 
disease have been described, both, in Professor Sanger's opinion, seeming 
quite authentic. Deciduoma malignum, or malignant degeneration of 
relics of the foetal envelopes and appendages, is a disease which has been 
repeatedly noted during the past ten years on the Continent. The very 
existence of this disease, as distinct from ordinary sarcoma following 
pregnancy, has recently been disputed in this country (50<x). If malig- 
nant degeneration of a piece of placenta or chorion can really produce a 
large uterine tumour followed by metastatic deposits in the abdominal 
and thoracic viscera, it is not surprising that a similar malignant change 
may occur in a tubal sac in ectopic pregnancy. 

Sanger holds that the possibility of deciduoma malignum following 
tubal pregnancy being established, we have one more argument not only 



DISEASES OF THE FALLOPIAN TUBES 827 

for active interference in cases of abnormal gestation, but also for the 
extirpation of tubal moles and appendages where " tubal abortion " has 
occurred. I leave the question to the consideration of obstetricians ; 
the subject of tubal gestation is treated in another section of this work. 
I felt, however, that deciduoma malignum must be mentioned under the 
head of malignant new growths affecting the tube. 

Finally, I say "malignant," not "cancerous," or "sarcomatous," 
because the few authorities who have observed deciduoma are not quite 
agreed as to the precise nature of its malignancy. 

Albax Doran. 

REFERENCES 

1. Ballantyne and "Williams. "The Histology and Pathology of the Fallopian 
Tubes," Brit. Med. Journal, vol. i. pp. 107, 168. — 2. Bandl. "Die Krankheiten 
der Tuben, der Ligameute," etc., Billroth und Liicke, Deutsche Chirurgie, 1886. — 
3. Barth, see Sanger. — -4. Cart. "De ractinomycose." Archives generales de 
medecine, vol. clxxiii. 1894, p. 342. — 5. Chaffey, W. C. " Pyosalpinx in a Child." 
Trans. Path. Soc. vol. xxxvi. 1885, p. 303. — 6. Chiari. " Zur pathologischen anatomie 
des Eileiterkatai-rhs," Prager Zeitschrift fur Hiilkunde, vol. viii. — 7. Choux. " Etude 
clinique et the'rapeutique de I'actiuomycose," Archives generales de medecine, vol. i. 
181)5, p. 664. — 8. Chrobak. Knauer " Ein Fall von priniiiren Carcinom der Tube bei 
einer Tubo-ovarial Cyste," Centralhlatt f. Gynlik. 1895, p. 574. — 9. Coe. "Neoplasms 
of the Tubes," Mann's American System of Gynxc. vol. ii. p. 895. — 9a. Cullen, T. S. 
" Tuberculosis of the Endometrium," Johns Hopkins Hosp. Rep. vol. Iv. pp. 367, 441. — 
10. CuLLixGWORTH. (a) " The Value of Abdominal Section in certain Cases of Pelvic 
Peritonitis," Trans. Obst. Soc. vol. xxxiv. 1892. (6) " Primary Carcinoma of the 
Fallopian Tube," Trans. Obst. Soc. vol. xxxvi. 1894, p. 307. — IL Demoxs. " Epan- 
chements pleure'tiques complicant les kystes de I'ovaire," Bulletins et memoii^es de 
la Societe de Chirurg. de Paris, vol. xiii. 1887, p. 771. — 12. Dixox-Joxes, Charles. 
"Three Cases of Myeloma (Sarcoma) of the Fallopian Tube," American Journal of 
Obstetrics, vol. xxviii. 1893, p. 324. — 13. Dixox-Joxes, Mary. "The Minute Anatomy 
of the Fallopian Tubes," America)! Journal of Obsteti^ics, vol. xxix. 1894, p. 785. — 14. 
DoLERis. " Tumeur vegetante de la muqueuse tubaire ; Papillome endo-salpingitique ; 
Echec du traitemeut intra-uterin ; Ablation par laparotomie," Bulletins et mernoi)^es de 
la Societe Obst. et Gynec. de Paris, pour ra?(??e'e 1S90. — 15. Dorax. (a) " Papilloma of 
the Fallopian Tube, associated with Ascites and Pleuritic Effusion," Trans. Path. Soc. 
vol. xxxi. 1880, p. 174; (&) Ibid. vol. xxxviii. p. 241 ; (c) "Papilloma of both Fallopian 
Tubes and Ovaries," Ibid. vol. xxxix. p. 201; {d) "Primary Cancer of the Fallopian 
Tube," i^JK?. same volume, p. 208 and vol. xi. (sequel to same case) p. 221: (e) Ibid. 
vol. xli. 1890, p. 202; (/) "Papilloma of the Fallopian Tube and the Relation of 
Hydroperitoneum to Tubal Disease," Trans. Obst. Soc. vol. xxviii. p. 229; (g) Ibid. 
vol. xxix. 1887, p. 186; (h) "Cases of Tuberculous Disease of the Uterine Appendages 
and Peritoneum," Brit. Med. Journal, vol. ii. 1893, p. 887; (i) Figured in a woodcut 
illustrating " Two Cases of Ovariotomy performed twice on the same Patient," Lancet, 
vol. ii. 1894, p. 1415. — 16. Eberth and Kaltexbach. "Zur Pathologic der Tuben," 
Zeitschrift f. Geburishiilfe U7id Gynlik. 1889, p. 357. — 17. Eve, F. S, -See Lawsox Tait. 
" An nndescribed Disease of the Fallopian Tubes," Trans. Obst. Soc. vol. xxv. 1883, p. 249. 
— 17a. F. Fabricius. Archiv f. Gynlik. \o\. \. 1S9(], -p. 3S5. — 18. Fearn. Leopold's 
Arbeiten aus der KUniglich. Frauenklinik. Dresden, vol. ii. p. 337. — 19. Frommel. 
" Beitrage zur Histologic des Eileiters," Verhandlungen der Beutsch. Gesellschaft f. 
Gyndk. 1885, p. 95. — 19a. Godart. Annales de Vinstitut St. Anne, Brussels, 
No. 4, March 1896. — 20. Gottschalk. " Primares Tubensarcom," Centralbl. f. 
Gynak. 1886, p. 727. — 21. Griffith, Walter S. A. "Tubercle of the Ovaries," 
Trans. Path. Soc. vol. xl. 1889, p. 212.-22. Hartmank. " Pyosalpingites gono- 
coccienes sans obliteration du pavilion de la trompe," Annales de Gynec. et d'Obstet. 
vol. xliii. 1895, p. 333.-23. Henxig. Die Krankheiten der Eileiter und die 
Tubenschwangerschaft, 1876. — 24. Illich. Beitrag zur Elinik der Actinomykose, 
1892, pp. 102-7 and 138.-25. Jaxi. " Ueber das Vorkommen von Tuberkelbacillen in 



828 SYSTEM OF GYNECOLOGY 



gesunden Genitalapparat bei Lungenschwindsucht," Virchow's Archiv, vol. ciii. p. 522. — 
26. Janvrin. " A Case of Myxo-Sarcoma of Fallopian Tube," Annals of Gynsecology, 
vol, ii. p. 357. BostoD, U. S. A, — 27. Keating and Coe. Clinical Gynsecology, Medi- 
cal and Surgical, by American Teachei-s, 1895. — 28. Kossmann. " Zur Pathologie der 
Urinierenreste des Weibes," Monatsschrift f. Geburtsch. und Gyndk. vol. i. 1895, p. 97. 
— 29. Landau and Rheinstein. " Beitrage zur pathologlschen Anatomie der Tube," 
Archiv f. Gyndk. und Geburtsh. vol. xxxlx. p. 272. — 29a. Ibid. Loc. cit. p. 273. — 30. 
Martin. Die Kimnkheiten der Eileiter, 1895. — 31. INIenge. " Ueber tuberkulose Pyo- 
salpinx," Centralbl.f. Gyndk. 1894, p. 24.-32. Munster and Ortmann. " Ein Fall von 
Pyosalpinx aufTuberkuloserGrundlage, "^rcA./. Gyndk. p. 97. — 33. Ott. Beitrdgezur 
Kentniss der ektopischen Formen der Schwangerschaft. Leipzig, 1895. (For the case here 
quoted see p. 31, and Fig. 7 in Dr. Von Ott's work.) — 34. Orthmann. " Ueber Carcinoma 
Tubse," Zeitschrift f. Geburtshiilfe und Gyndk. vol. xv. p. 212. — 35. Parona. " Caso 
di Lipoma all ovaia ed ovidotto di destra," Annali di Ostetricia e Ginecologia, 1891, p. 
103. — 36. Pean. Diagnostic et traitement des tiuneurs de V abdomen et du bassin, vol. 
iii. " Tumeurs primitives des Trompes," pp. 547 to 571. — 37. Penrose and Beyea. 
" Tuberculosis of the Fallopian Tubes," Amer. Jour. Med. Sciences, vol. cviii. 1891, p. 
520. — 37a. Recklinghausen. Die Adenomyome und Cystadenome der Uterus- und 
Tubenivandung, 1896. — 38. Reymond. Contribution a Vetude de la Bacteriologie et de 
r Anatomie Pathologique des Salpingo-Ovarites, 1895. — 39. Ritchie. "Dermoid Cyst 
developed in the Fallopian Tube," Transi Obstet. Soc. vol. vii. p. 854. — 40. Routier. 
" Epithelioma primitif de la Trompe," Annales de Gyne'c. et d'Obstet. vol. xxxix. 1893, 
p. 39. — 41. Sanger, Professor M. " Etiology, Pathology, and Classification of Salpin- 
gitis," Amer. Journ. Obstet. vol. xx. 1887 ("Actinomycosis," p. 320); also chapter 
on New Growths in Martin's Die Krankheiten der Eileiter. — 42. Scanzoni. Lehrbuch 
der Krankheiten der weiblichen Sexual-organe, 5th ed. 1875, p. 511. — 43. Schramm, 
" Zur Kenntniss der Eileitertuberkulose," ^rc/riu/. Gy/iaA;. vol. xix. — 44. Schwartz. 
" Fibrorayome de la Trompe Uterine drolte a son origine ; Metrorrhagies et accidents 
nerveux; Laparatomie ; Ablation; Reduction du pedicule; Gue'rison," Bulletins ct 
memoires de la Societe Obstetrique de Paris, 1890, pp. 73-76. — 45. Schroeder. Die 
Krankheiten der weiblichlen Geschlechts-organe, 7th ed. 188'), p. 361. — 46. Senger, 
Emil. "Ueber ein primares Sarkom der Tuben," Centralb. f. Gyndk. 1886, p. 601. — 
47. SiLCOCK, A. Quarry. "Tubercular Endometritis and Salpingitis, associated with 
Accumulation of Tubercular Matter in the Body of the Uterus and Fallopian Tubes of a 
young Child," Trans. Path. Soc. vol. xxxvi. 1885, p. 303. — 48. Simpson, Sir J. Y. 
Clinical Lectures on the Diseases of Women, 1872. Fig. 93, p. 540. — 49. Smyly. 
"Report of 112 Abdominal Sections performed in the Rotunda Hospital," Dublin 
Journ. of Med. Science, vol. xcv. 1893, p. 285.-50. Spaeth. " Ein Fall von Fibroid 
des Eileiters," Zeitschrift f. Geburts. und Gyndk. vol. xxi. p. 363, and plate x. — 50a. 
Spencer, Herbert, and others. Trans. Obstet. Soc. vol. xxxviii. 1896, Part 2. — 51. 
Stewart, Sir T. Grainger. " Note on a Case of Actinomycosis of Ovaries and Liver." 
Edin. Hosp. Rep. vol. i. 1893, p. 96. — 52. Sutton, J. Bland. Surgical Diseases of the 
Ovaries and Fallopian Tubes, passim. — 53. Treub. Leerboek der Gynaekologie, 1895, 
p. 470. — 51. Veit. Report of a Meeting of the Berlin Obstetrical and Gynsec. Soc, 
Zeitschr. f. Geburts. und Gyndk. vol. xvi. 1889, p. 212.-55. Warnek. " Trois cas des 
tumeurs des Trompes compliquees de la torsion du pedicule." Nouvelles archives 
d'Obstet. et de Gynec. 1895, p. 81. — 55. Weichselbaum. Elements of Pathological 
Histology. Translated by Dr. Dawson, 18.^5, p. 318. — 57. Westermark and Quensel. 
" Ett Fall af dubbelsidig kancer i Tubae Fallopii," Nordiskt. Mediciniskt Arkiv, vol. 
xxiv. 1892. — 58. Williams, Sir John. On Cancer of ^/le CT/'e^'M-s, being the Harveian 
Lectures for 1886, plate xvi. — 59. Williams, J. Whitridge. (a) " Contributions to the 
Normal and Pathological Histology of the Fallopian Tubes," Amer. Journ. M'^d. Sci- 
ences, vol. cii. 1891, p. 377 ; (6) " Tuberculosis of the Female Generative Organs," Johns 
Hopkins Hosp. Rep. vol. iii. 1892.-60. Wynter, W. Essex. "Primary Carcinoma 
of the Right Fallopian Tube, with large Cyst in connection with the New Growth," 
Trans. Path. Soc. vol. xlii. p. 221. — 61. Zemann. Medicin. Jahrbuch des K. K. Gesell- 
schaft d. Aerzte in Wien, 1883.-62. Zweifel. Verlesungen Uber klinische Gyndkolo- 
gie. Berlin, 1892, pp. 139-142. 

A. D. 



W 05 00 X 















0.5 



•S 2 « S 

O » - cj 












_2 => 



» cc O) 



8 >>c 



M 3 



II 






-c > <» fee - 

!a ? =c c ^ 

-ri ? "3 -r « 

:3 fee t< S o 

J = .2 "- 1 

S 3 f;^ 2 '"' 



013 c.s 

till 

:S S § =* 

-gosl 

-o 5 '^ .H - 
^■^^-^ 



^ " 's js^ 



^ 3 



- _ CD 






j3^ 
j<0 to 



^o'^^'o S? 



^•-S.S3 



CS C > 3 
is g o o 



gill 






ti^ G, 



Ph.s3 



•=s 



o o 
go 

02 .S O 5i- 

c 
fee 



"z 9 



O s 



2^^ 



o fee 

rgsa 

i-S^ a, 



r3d| 

S to 

C5 13 fc. a. 









III 



<^>. 



c3_ 






to C « 



s 









fee -/) CO 

^5^ to -S 

O C to S 






3 S 



a-2- 



S o = "' fee 

"^ c .2 c js 



to C Ti 

o fee-+3 

13 = 5.5 
(1h I g So 



K* c fee o fee 
o o t. ci 

feeco 






i^S 



829 



pq 






t3 






H 






^ 






<1 












PM 






O 






Hi 




<i> 


hJ 




rO 


<! 




,^ 


I^ 




bs 


^ 




^ 


g 




1 


O 




■5^ 




<l 


'^ 


^ 


,^ 


<! 


o 




W 


^ 


S 


OJ 




^ 


M 


o 


^ 


P 


M 


^ 


H 




^ 




1 


e 


"A 




(O 


cb 


1— 1 


•<?* 






S^ 


1^ 




?^ 


>H 




O 


W 




1 


-^ 




1 


^ 




< 


w 






P4 






Pm 






o 






cc 






W 






m 






< 






o 







-2 £ 



1=1 S 2.2 



r-^ I— i <» 






03 ^„- 

c a o ^22 



^ ^ », 
£? « o 









&i3 .2? • Cu'^f 



L-|i^^!l 


•sl^-ft^l 


lljl%sli 




^^^N;sSfi^§ 


=<^Sp,* 



-2 o|"^.2 b 



"|o|| 






g S « 03 X 



S" Qi to CI i ^tn rA ofS 



oS 'i' C3 



2 g n S'^'^ S 



"^S - o fl « 

p" ? S 'S 
^■2 « „• ^ 






\^B 





43 13 


c^ 






n 






05 


? 


<p 




is 












O 




"3 


o 














q 


C 


a 




s 






o 


fl) 


c -^ 


U 


n1 


-73 42 






a 


03 


2 


a = 



c3 Uh 

»a=3S 



11 



03 p,.ii 

a ^"< 

i^-tj a 0) <u 

,£! .5 +J oa 



t^j c3^ 

•ga-" 
.s ^ 



'p a ^ 



O 00 



T3eo 



w 03 ai 

PS "^ ^H <» 

,, 00 <» 03 

- ."S o o> 



5 g <3 >. 



!r g o 03 ^ ■ 

o be a 03 ►t 



<1 









£a 



S 2 =3 *=- 

fcc a 8 <« , 

•r _ 43 a =; 



-55 o 



aaa®. 

•^^ O 43, 



1 .22 .S 



) 43 43 O OJ O 



O g 

a a> 



«-a:^„S^-5c3|§i 

=2fe>? 



S hri o o M _ . . , , 

«* O £-2 !3 O 2 ^ ^ 

: w S ii S .2 






■TS <B V 



.2so 



03 tT 

c5 & 






830 






U^.g^'f 












5 S S :s .?. « 03 
'? !E S --• a-c! o 

Q ^ M lO o ? I— ' 






oojto-SMOa-us-irta) 



o h S 3 



S S £ 2 



as §3^ 

P=ii ^ 2 =5 

*»j 3 g s a 









03 •-^ O 

H m (u 
O c3 « 

lllll 

cS S ci cc 






.2 5 ^ C3 =3 

Sill 









o 3 ^-, c .ii • 



« a -a g g S 
3 .5 +^ ^ j; cu 

o a5-G ? c 

«^ 5 c ti a 
O &. ci s s 






'^ 5 3 c3 5 'S 

|.S^SJ3S-2r- 



^=mt2a 



^ o o) <» ji;^ 

"■H to 

8 fi"^ « 
aj g a S_^' 



saS,^^ 



03^ « 



s: 5 G 

2 "=' 

y;aa 



^J 



«g2 



-a c = a 

-s ?* a o 



■p a s- ^ 

S 3 StS 



a'. 



O ' t- c3 



^.5 



Free, watery di 
charge. Abdoir 
nal pain, emaci 
tion. Twotumou 
felt through pa 


-2 


Ilypogastr 
pains ; metrorrh 
gia; elastic tumo 
of the size of 
fist in right si( 
of pelvis ; small 
tumour to left ai 
above uterus 



"S^'S ^ --.2 
«§flg?.2-g 

^ft««otl3 



3 2 fcD S ^ci-^ a 
o - -3 p,.2 ==-i: 
^ g " ^ ■« . _2 

'^ c3 oj-p c3 

2 .1 S o .SP-iJ 2 e 

«^.23 I 3 S 53 >> 
'CH-3 -M O 3 P<P 






2 eS <U c3 
,3 to to !> 



0/ fcc 



log 



831 





Tuffier, Annales 
degynec.ctd'ohstet. 
vol. xlii. 1894, p. 
208 ; and private 
correspondence 

C u 1 1 i n g w o r t h 
and Shattock, 
Tra7is. Obst. Soc. 
vol. xxxvi. 1894, p. 
807 ; and private 
communications 
and personal in- 
spection of speci- 
mens 

Warnek, Nouve.l- 
les Archi v e s 
d'obsUt. et de 
gynec. 1895, p. 81 

Ditto. 

(" The case will be 

published in full") 


o 


5 UU%i 

1 i I ^f^ 


1 

> 

2 
O 


JSii iiMii :!ia 

^iil ? MH III } ■ t 


a 

H 
o 
1 


|ii|is li'ij jiiisi P 

ifflii WJiJ iilKi i: 

113 sli lii^ii ^lllili III 






Duration of 
Symptoms 

before 
Operation. 


J 5 
a a 

i 1 : : 


1 

a 


•E|llll till illilillii r^ 

^^. i!^-« 111 II :!ii::-pP 1=1 
smitt s-=r: isi: Hif.i lilt 


11 




ill 


^ |-i4 

^ 3 § j^ 2 


Age. 
Married 

or 
Single. 




6 
'55 


O -rH Ofl CO 



832 



'2 ?^ '^iS 

§ s 2 s g": 
■^ s « s 



<s ~ C::s 



|£ill?15»| 

;?= « g S 2 § ^ g-= c 






' ^. -t -^ CO ^^'^ 






-^.2 



°5S. 



3 cj 



to C S 






^ to 



3 to tea O 

? S 'C c <» 

S3 O to 



~ S-S r- c3 



CI, 3 4^ C S =S 
es -^^ ti =S o ^ 



•r- -t: p CJ « 



o c *i o 






"—■^ .S to O *J 
O '-S M _£ 3 

.5 o -o'5=2 






.2 E-i 






o 






§ „ n ?r o 3 o ^ ;q 









>-. •:- 






O ri S ;j; Xf ;i^ 

5 .2 -r <3j ^ '^ 9 := 

C — CS — 5J c — ^? 



Sit 

«^ s o 



3'* = §-5 



5j .3* X OJ 



^:= 



tc 3 ^ 3 :3 



02 



^S 



833 



3h 



r3 




1 


^^-^ 


1 


^ 


OJ 


03 


W 


^ 




|i 




to 


^ 


ao 


^ 


5r5 




o 


Oh 




o 


*o 




1 


<^ 


<i> 


t^ 




W 


<s> 


PH 


«1> 


H 


1^ 




=^ 


O 


^ 

<!:> 


&q 


^ 


cc 




*1 


rO 


W 


^ 




s^ 


P 


O) 




<ii 


H 


g 


<tt 


«0 


^ 


50 





s 


h^ 


?5i 


<; 








f^ 


g 




(^ 


>^ 


r--i 


<1 


•£> 


^ 


^ 


05 


?; 


?lH 







Prager 3Ied. 
Woehenschrift f. 
Heilkunde. vol. 
xvi. 1895, p. 143 

Savor " Cvstitis 
crouposa bei saue- 
rem Harn," Wie- 
ner klin. Woehen- 
schrift, vol. viii. 
1895, p. 775 

Senger, Central- 
llatt /. GyndJc. 
1886, p. 601. 


o 
O 


1 1 s 

5 1 g 


a 

1 


III °| S 

s-iS si 1 

ill la H 

II il ill 11 

O 03 03 oP, H 


3 
O 

a 

H 
o 


'mm ^'J ffii 
l^:iiT ■ III i|:i 

^ IS mil pq ^^11 § ^.sili 


|l 


t- O O 03 


Duration of 
Symptoms 

before 
Operation. 


11 ^ini 1 


a 

o 
a, 

a 
o 


lliiiii -IBIii^i nil 

t^a.2^§>§;§§ aa'silg^.^l ^aH^-i 


si 


" ^ 1 . 




liH -S £ 


Age. 

Married 

or 

Single. 


§S S JSg 


1 


l-H tH 



834 






Sit- 






111 



^o-^ 



■^ ft: 






>> 2 



60 



,0 IE 5 



o 

o 3 y 
P5 SC fcl) 



•5£ =s 

■■0 d O O 

=3 p 5 a 



=5 S . 



§3 



• S * = 






^M' 



^23 



r^ = •= --r i - 



o tc ^ 



SI 



i S S'B ^ 



1=^ = 1^^ 



-^ ?= = M 



s « 



§1 




S o 



SS 






!§>. 



835 



836 SYSTEM OF GYNECOLOGY 



DISEASES OE THE OVAEY 

Tumours of the Ovary. — Solid tumours of the ovary arise from 
the connective-tissue stroma ; cystic tumours, on the other hand, although 
their walls and a large part of their solid contents have a similar origin, 
appear to arise either from Graafian follicles, or from ingrowths of the 
germ epithelium which covers the ovary. 

I propose in this article to avoid, as far as possible, the minute sub- 
division of ovarian tumours which has been the first and the natural 
result of the labours of investigators in a new field; and also the some- 
what speculative views of the origin of the different varieties. While, 
for the most part, the characteristic features of the principal classes are 
readily recognisable, the variations and combinations of them are so 
numerous that, in the present state of our knowledge, it is often not 
practicable to classify a particular tumour with certainty. Innocent 
kinds pass by almost insensible gradations into malignant ; solid tumours 
develop cysts, aod cystic tumours develop solid masses ; papillomatous 
growths develop both in cystic tumours and on the surface of the ovary 
without any cystic formation ; and cysts with papillomatous or dermoid 
contents occur either alone, or as parts of tumours of different kinds. 

I propose, therefore, to describe first the characters common to all, 
and then to point out some of the features of special kinds. 

The first requirement for a systematic investigation of ovarian 
tumours is undoubtedly a knowledge" of the structure of the healthy 
ovary. The absence of this knowledge, and the inherent difficulties of 
the subject, have led and still lead to much difference of opinion on 
points which by this time should have been settled. 

The bulk of the solid parts of all ovarian tumours is composed of 
well-developed connective tissue, or of a spindle-celled stroma identical 
with that of the normal ovary, or of both these constituents. The 
spindle cells have been identified by some observers as connective-tissue 
corpuscles ; by others as unstriped muscle ; or in some cases as sarcoma 
cells. The fact that the spindle cells of such tumours are for the most 
part indistinguishable from those of the normal stroma, and that in solid 
tumours the development of these cells into fully formed connective- 
tissue may often be distinctly traced, should lead the observer to hesitate 
before describing a tumour as a myoma, or as a spindle-celled sarcoma, 
on anatomical evidence alone. 

The connective tissue of cyst walls varies greatly in vascularity; the 
greater the bulk of solid tissue the more vascular it is : the walls of 
unilocular cysts with fluid contents are often parchment-like and almost 
bloodless. 

All cystic tumours, with the exception of those formed by degenera- 
tion from solid growths, are lined more or less by epithelial structures, 



DISEASES OF THE OVARY 837 

upon which, their cystic character depends. ]^ow, excluding the lin- 
ing of the vessels, epithelium is present in the normal ovary in two 
forms only : firstly, as the germ epithelium covering almost the entire 
surface of the organ; and, secondly, as the epithelium lining the 
Graafian follicles. These parts we should naturally regard, therefore, 
as the seats of development of all cystic tumours. No author now 
regards the epithelium of the vessels as the source of cystic tumours ; 
and the evidence of many observers is accumulating in favour of the 
follicular source of most ovarian cysts. We are, however, still unable 
to explain the great differences which are found not only in the several 
tumours, but also in the several compartments of the same tumour. 

Hydrops Follicidorum. — The simplest cysts are the small unilocular 
dilated follicles known by this name. They are generally multiple and 
small in size ; although occasionally a single cyst may be as large as a 
fist, a man's head, or even yet larger. When the cysts are minute, the 
ovary may be but little enlarged, some of them projecting on the sur- 
face, others lying deep in the stroma. The fluid contained in these 
cysts, as in all ovarian cysts, may be clear or blood-stained. The lining 
membrane is clear and transparent, and covered with columnar epithe- 
lium. As a rule the cysts are few in proportion to the amount of 
stroma; but occasionally they are very numerous, and the stroma so 
scanty that the ovary is converted into a small mass of delicate cysts. 

It is quite common to meet with ovaries, otherwise healthy, with a 
single unilocular cyst as large as a pigeon's or a small hen's q^% ; it is 
situated usually at the outer extremity. 

The causation of these cysts is probably a very simple matter. It is 
believed that the normal rupture of the follicles is prevented by a 
thickening or undue toughness of their walls, resulting, perhaps, from 
inflammation ; and this leads to an increased accumulation of their fluid 
contents. Occasionally ova can be detected in them. Such cysts have 
been known to occur in the foetal ovary. 

These forms of cystic ovary rarely give rise to symptoms, or interfere 
with the normal functions of the organ ; menstruation, ovulation, and 
pregnancy take place in their usual course. Progressive enlargement 
beyond a moderate size is not common, and any of the cysts may rupture 
and be cured spontaneously. 

Cystic Corpora Lutea. — These also are unilocular cysts, and are usually 
of the size of a pigeon's egg ; though occasionally they have been found as 
large as a small apple (Gottschalk and Nagel). They were first described 
by Rokitansky. The wall is comparatively thick, and is lined by the 
yellow and apparently folded membrane characteristic of these bodies, 
altered by pressure and stretching, and stained by the blood which usually 
forms their contents. Careful observation of this lining membrane by 
the eye and the microscope will distinguish them from other small cysts 
containing blood. It will not be possible to explain the occurrence of 
these cysts until our knowledge of the natural history of normal corpora 
lutea is more complete. I have examined specimens which have led me 



838 SYSTEM OF GYNECOLOGY 

to believe that a corpus luteum may be developed in an unruptured follicle ; 
if this be correct, dropsy with subsequent haemorrhage from the very 
vascular lining membrane is a reasonable explanation of the cysts. 

Proliferating Cystoma. — I now come to a far more difficult and com- 
plicated class, the various forms of proliferating cystoma. This class 
comprises the great bulk of ovarian cystic tumours. They vary greatly 
in size : occasionally they are met with at an early stage, and are then 
very small ; if not removed by operation they may attain enormous 
dimensions, so that the emaciated woman may almost appear to be an 
appendage to the tumour. 

These tumours are composed of a greater or smaller number of primary 
cysts which contain secondary cysts in their walls, or projecting in more 
or less solid masses into their cavities. There is every variety of size in 
the primary and secondary cysts. Usually one or more greatly exceed 
the others in bulk : many of the cysts rupture and communicate with 
each other by small or large openings in the septa ; in consequence some 
disappear, and are recognised by an orifice in a septum closely com- 
pressed against the inner surface of the larger cysts. The very large 
cavities are usually, if not always, formed in this manner. 

A cyst composed of a few thin-walled cavities may by fusion become 
practically if not strictly unilocular. 

Fusion of cystic tumours of both ovaries may also occur in the same 
way, and form a single tumour, the nature of which may be recognised 
by the presence of two characteristic pedicles, one on each side of the 
uterus. 

Structure. — The cyst walls are composed mainly of dense, more or 
less vascular connective tissue, arranged chiefly in bundles of long white 
fibres ; the most recently formed parts contain also the characteristic 
spindle cells of the ovarian stroma, and in the neighbourhood of the 
pedicle non-striped muscle fibres have been found by Olshausen and 
others. 

The walls, therefore, if at all thick, are very tough and strong ; some, 
however, being naturally thin, or being weakened by papillomatous 
growths, secondary cysts, or some partial degeneration, may rupture 
from very slight or inappreciable exciting causes. 

The epithelium is polymorphous; cylindrical, ciliated, and goblet 
<3ells being the principal forms: the cells are sometimes quite irregular in 
shape, sometimes flattened, and sometimes even absent. Usually they 
form a single layer, sometimes several layers. Where proliferation is 
taking place cup-shaped depressions occur which, gradually invading the 
€yst wall and becoming closed at their mouths, form secondary cysts. 
Groups of cysts thus formed may project into the principal cavity and 
make semi-solid masses, which not rarely attain considerable size. On 
section these masses are seen to be composed of small secondary cysts, 
and they may thus be distinguished from the papillomatous growths 
occasionally found in these cysts. 

Much less frequently there are found in some of the cavities of these 



DISEASES OE THE OVARY 839 

tumours connective-tissue buds covered with columnar epithelium in the 
form of dendritic masses which may fill the containing cysts. Some- 
times they perforate the wall of the cyst and spread to adjacent ones ; 
or, if the main cyst wall be perforated, they spread over the adjacent 
peritoneum, and particles, becoming detached, may be carried to distant 
parts of the abdominal cavity and grow there. Such papillomatous 
masses may be found with three different characters : — (i.) Developing 
in certain loculi of otherwise typical proliferating cysts, (ii.) Develop- 
ing in the principal cyst and in any secondary cyst — such tumours are 
as a rule not very large, and show a tendency to invade the broad liga- 
ments, (iii.) Developing on the surface of the ovary without any evi- 
dence of having been previously contained in a cyst. Such cases are 
very rare, and are well described as "surface-papillomas." 

A different origin is, of course, possible in some cases of surface- 
papilloma ; the growths may originally have been developed in a cyst 
which was perforated and has entirely disappeared. 

Microscopic sections of these masses closely resemble transverse 
sections of the middle and outer parts of the Fallopian tube ; there is 
little tendency to the formation of cysts. Small sand-like concretions, 
called psammomas, are frequently present in them, and are sometimes 
also found in the walls of proliferating cysts. 

It will be noticed that the proliferating cj^sts are lined almost 
uniformly by structures closely resembling certain mucous membranes 
with their simple tubular glands ; and as a result the term " glandular " 
has been applied to them. Waldeyer, Bland Sutton, and others have 
drawn attention to these resemblances. 

Papillary cysts are more frequently bilateral than the proliferating 
cysts. The rare surface-papilloma is generally accompanied by abundant 
hydroperitoneum. In the latter case Olshausen states that the cubical 
surface-epithelium of the ovary is directly continuous with and gradu- 
ally lengthens into the columnar epithelium of the papilloma. 

Recently Whitridge Williams (37) has carefully investigated the 
papillary tumours of the ovary. He is of opinion that only a small pro- 
portion of them invade the broad ligaments, while at least half of them 
are bilateral. He finds that they are lined by a single layer of columnar 
cells, except at points where new papillae are being formed, when the 
layers are multiple. The epithelium is often, but not invariably ciliated. 
He also finds the same characters in surface-papilloma, of which he has 
collected twenty-six well-described cases. The entire surface of the 
organ may be covered with papillae, the ovary itself being almost 
unchanged ; although at times epithelial processes and duct-like struct- 
ures may be found to extend into the stroma, and from these papilloma- 
tous cysts may arise in the substance of the ovary. Psammomas are 
present in large numbers. He believes that the surface papillomas 
arise from the germ epithelium. 

Contents. — The fluid contained in proliferating cysts is usually vis- 
cid ; but it varies greatly in consistence and colour in different tumours, 



840 SYSTEM OF GYNECOLOGY 

and even in different cavities of the same tumour. In some it is so viscid 
that it will not flow^ and has to be removed in handfuls from the cysts 
or the peritoneal cavity; in others it is quite thin, and every inter- 
mediate degree of viscidity may be found. The fluid is at first colour- 
less, and either transparent or opaque ; but from admixture with blood 
and subsequent changes, the colour may vary through every shade of 
blood-red to brown, green, or yellow. 

The specific gravity varies from 1-002 to 1-020, the average being 
perhaps about 1-012; higher that is than in the case of broad ligament 
cysts, and some papillomatous cysts. 

Histologically the fluid, however viscid, is structureless ; though at 
times a delicate connective-tissue reticulum may be found in colloid 
material. Blood corpuscles are often present, and epithelial cells 
which vary, of course, in character, and in the different degrees of 
degeneration. Sometimes crystals of cholesterin are found. The 
reaction is neutral or alkaline. Various forms of albumin are present 
in solution, such as metalbumin, paralbumin, albumin peptone, and so 
forth ; to these bodies the viscidity of the fluid is due. 

Dermoid Structures in Ovarian Cysts. — These form a very remarkable 
and not common variety of ovarian tumours (3-5 per cent acccording to 
Olshausen). Both structurally and clinically they present characteristic 
features, by which they may be recognised. There are three principal 
varieties of these tumours, which are always cystic : (i.) A unilocular 
cyst possessing the characteristic features, (ii.) A cyst with two or more 
cavities each with characteristic dermoid contents ; the component cysts 
having probably arisen independently, not by proliferation, (iii.) An 
ordinary proliferating cyst, one or more cavities of which contain char- 
acteristic dermoid structures. Out of thirty-one dermoid cysts Doran 
records four of this kind. 

The anatomical structures characteristic of these, as of all dermoid 
tumours, are portions of true skin present in the cyst wall. Occasionally, 
perhaps, the whole cyst may be lined with cutaneous structures, but 
usually there is only a relatively small, well-defined patch of skin. 

Section of these patches reveals the histological characters of true 
skin ; often with the hair, sweat and sebaceous glands resting on a layer of 
subcutaneous fat which unites it to the cyst wall. Teeth, bone, cartilage, 
and, much less frequently, other structures — such as non-striped muscle 
and nerve tissue — may be found in different parts of the cyst wall. 

The dermoid mass sometimes curiously resembles the mamma in 
shape, and may even present a rudimentary nipple, as described by Von 
Velits, Bland Sutton, and others. The mass is, however, composed not 
of mammary gland tissue, but of fat; the gland tubes present being 
obviously modified sebaceous and sudoriparous glands. 

The hair is developed from follicles in the ordinary way, and may 
grow to a considerable length : it is often detached, and then, if long, 
may be coiled up into balls; or if short, mixed up with the other 
contents of the cyst- The colour bears no necessary relation to that of 



DISEASES OF THE OVARY 841 

the normal hair of the individual. Irregular plates and masses of bone, 
and occasionally nodules of cartilage, are found embedded in the cyst 
wall. Teeth may be found projecting from these bony plates ; they are 
often irregular in shape and vary greatly in number : usually they are 
few, but as many as 300 have been described by Autenreich. The 
characters of these dermoid teeth have been fully described by Mr. 
Bland Sutton. Xails have been found by Cruveilhier and others. Mr. 
Knowsley Thornton records a dermoid containing a mass like a mal- 
formed limb with long nails at the extremity. 

Dermoid cysts usually contain a thick, white, pultaceous or putty-like 
substance, consisting of fat, cholesterin, epithelial cells and hair, which 
may be rolled up into coils or balls. The fat is sometimes fluid at the 
body temperature. Occasionally large numbers of small solid balls of fat 
are found. Bland Sutton has described one containing several hundreds 
of these bodies ; each one examined had a short hair coiled up within it. 

Dermoid cysts, like the other varieties, may contain sarcomatous or 
carcinomatous masses ; and there is reason to believe that they are 
more often followed by malignant secondary growths than are the other 
forms of cysts. 

A remarkable case of Martini's is recorded by Kolaczek, who on 
removing a dermoid cyst found the peritoneum studded with numbers 
of small yellowish bodies the size of peas, many of which contained a 
thin woolly hair attached to the peritoneum. He supposed that they 
arose as a result of rupture of the cyst. 

Hydatids of the Ovary. — There is very great doubt whether any of 
the cases so recorded are really hydatids of the ovary ; most probably 
they are examples of hydatid cysts involving but not originating in the 
ovary. 

Schultze, in 1893, operated on a woman 32 years of age, and re- 
moved from the abdomen 30 hydatid cysts : the largest Avas 6 inches 
in diameter, and the right tube was stretched over it; it was apparently 
a cyst of the right ovary. The left ovary and tube were healthy. 
Several cysts had to be left behind, but the patient made a good 
recovery. Schultze admits there was no proof that the disease origi- 
nated in the ovar}^. 

Malignant Growths in Ovarian Cysts. — The presence of malignant 
masses in the walls of different varieties of ovarian cysts has already 
been referred to. The well-known clinical fact that a certain number of 
women die from malignant disease after ovariotomy, in whom at the 
time of operation the tumour was thought to be benign, is probably to 
be explained by the non-recognition of such malignant masses. 

Landerer gives details of three cases of proliferating cystoma with 
malignant growths in the walls. In two there Avere secondary groAvths 
in the tube of the same side, and in one both tubes were affected. 
Secondary nodules Avere also found in : — (i.) The utero-vesical cellular 
tissue and broad ligaments, (ii.) The mesentery, and parietal and 
visceral peritoneum, (iii.) The abdominal surface of the diaphragm. 



842 SYSTEM OF GYNMCOLOGY 

(iv.) The retro-peritoneal, inguinal, mediastinal, and bronchial glands. 
(v.) The parietal and pulmonary pleura, (vi.) The liver. 

The growths in the cyst wall were carcinomatous, arising from 
proliferating (glandular) processes of the lining epithelium, which were 
hollow or in some places filled with polymorphous cells; in others lined 
with columnar epithelium or dilated into small cysts. In other places 
well-marked alveolar cancer was present. 

In such cases metastasis occurs through the blood or lymph chan- 
nels, or by the migration of detached particles to distant parts of the 
peritoneal cavity. 

Landerer justly remarks that if apparently simple ovarian cysts may 
thus become the seat of carcinomatous growths, it is wise to remove all 
such tumours, however small, immediately they are detected. In the 
case of papillomatous cysts, it is not very uncommon at the time of 
operation to find that secondary papillom atous growths are present in the 
parietal or visceral peritoneum. These secondary growths probably 
arise by detachment and migration of papillomatous particles from a cyst 
which has become perforated, and from which papillomas protrude. 
This simple explanation does not, however, apply to cases in which 
secondary papilloma has been found upon the pleura; in such cases 
distribution must, of course, occur through the blood or lymph channels 
as in the case of true malignant metastasis. Indeed, it seems clinically 
established that papillomatous cysts are more nearly allied to malignant 
disease than are the simple proliferating cysts. It is a curious, but 
well-established fact, that secondary papillomas, not removed at the 
time of operation, disappear after the removal of the principal growth, 
and in no way prejudice the ultimate result of the operation. 

^olid tumours of the ovary, according to Olshausen, form about 5 per 
cent of all ovarian tumours. Like cystic tumours they may be either 
innocent or malignant ; they may also undergo cystic degeneration. 

The larger innocent tumours are composed of spindle-celled tissue 
similar to that of the normal ovarian stroma, with two well-marked 
differences ; namely, the tendency to develop into pure fibrous tissue, 
and the tendency to softening of the fibres, leading to the formation of 
cyst-like cavities like those which occur in uterine fibroids. Cysts 
may also arise by lymphangiectasis. Occasionally calcification is met 
with. 

Solid tumours, whether innocent or malignant, are often bilateral ; 
and this condition is therefore no important evidence of malignancy. 

The name fibroma is obviously correct for such tumours as these ; 
those who, like Mr. Doran, apply the name myoma must satisfy them- 
selves that the normal ovarian stroma is principally non-striped muscle. 

This variety of tumour is distinctly rare, but is probably the most 
common form of solid ovarian tumour. In general character it closely 
resembles the harder uterine fibromyoma : there is, however, one clini- 
cal distinction of great importance ; namely, that they are frequently 
accompanied by hydroperitoneum. Being very slow in growth and 



DISEASES OF THE OVARY 843 

generally discovered early, they do not attain a very large size. As they 
are formed by hyperplasia of the whole stroma, they maintain the gen- 
eral contour of the ovary. As a rule they are freely movable, having 
no adhesions, and are surrounded by fluid. The oviduct, though often 
thickened, apparently by simple hyperplasia, is not stretched over the 
growth, as in the case of cystic tumours, but lies free, because the meso- 
salpinx is not opened up by the growth. 

The tumours sometimes contain small cavities or cysts, rarely large 
ones ; these may be formed by dilated follicles, lymphangiectasis or soft- 
ening of the constituent iibres ; proliferating or papillomatous cysts have 
not, I believe, been met with in the same ovary. 

There is a peculiar form of fibroma of the ovary which, as it leads 
to no great enlargement of the ovary, is generally met with in the dead- 
house, or accidentally during operations. The ovary may be as large as 
a small hen's q^%, and is irregular in shape. On section the enlargement 
is seen to be due to the presence of one or more, sometimes of many 
oval bodies the size of peas or beans, well defined from the rest of the 
stroma by being paler in colour, and showing a sinuous arrangement of 
the fibre bundle. They are found to consist of well-developed white 
fibrous tissue, which stains with difficulty, and is less vascular than the 
surrounding stroma. They are identical, except in size, with corpora 
lutea in their penultimate stage ; and undoubtedly they are corpora lutea 
which have undergone hypertrophy instead of atrophy. The largest 
specimen I have examined was the size of a walnut ; it contained a con- 
siderable number of these bodies. 

They have also been described by Rokitansky, Klebs, and Klob. In 
Klob's case the tumour was as large as the foetal head. In Kokitansky's 
cases the largest was no bigger than a walnut. 

Dr. Mary Dixon-Jones has described and figured this form of tumour 
under the appropriate name of gyroma; but she believes these growths to 
be closely connected with those described as endothelioma of the ovary, 
and that they are developed from corpora lutea when found in the cortex, 
from endothelium when foimd in the medulla. 

The term " endothelioma " was first applied by Leopold, in 1874, to 
a peculiar form of fibroma of the ovary, containing numerous alveolar 
spaces packed with epithelioid cells. He traced the origin of these spaces 
to dilatation of lymphatic and capillary channels, with proliferation of 
their endothelium ; hence the name. Similar tumours have been since 
described by Marchand, Eosthorn, Amann, and others. The last author 
made the interesting observation that certain typical sarcomas of the 
ovary could be traced back to proliferation of the adventitia of the 
smaller vessels, others to proliferation of the endothelium of lymphatics 
and capillaries. Although there is much still to be learned about these 
tumours, it seems well established that they really do arise from the 
walls of lymphatics and blood-vessels, and that they must be regarded 
as closely allied to sarcoma. 

Sarcomaoftlie Ovary. — All authorities are agreed that our knowledge 



844 SYSTEM OF GYNECOLOGY 

of this form of malignant growth, is very imperfect. Primary sarcoma 
and carcinoma, in the form of solid tumour, are rare. 

Olshausen says that " the spindle-celled form of sarcoma is the most 
common ; mixed round and spindle-celled forms are met with, but true 
round-celled sarcoma is very rare." • ■ 

The consistence of these tumours varies much ; generally they con- 
tain cysts, and in size they may equal the fcetal head at term. The 
bundles of spindle cells do not differ materially from those of the nor- 
mal stroma, and between them are often large numbers of round cells. 
These tumours are closely related on the one hand to fibroma, and on 
the other to adenoma and carcinoma. 

Sarcoma carcinomatosum has been described by Spiegelberg, who says, 
" The tumours consist for the most part of round-celled sarcoma. In 
certain parts are large alveoli separated by a very vascular connective 
tissue, and containing large cells undergoing fatty degeneration, the 
whole being quite like carcinoma." 

Secondary sarcomatous growths are found most frequently in the 
stomach, liver, intestines, pleura, and peritoneum. 

Mr. Bland Sutton says, " It is important to remember that the ma- 
jority of solid ovarian tumours classed in museums as fibromata are 
examples of sarcomata." This statement requires further proof before 
it can be accepted ; it is at least certain that many tumours classed as 
sarcoma are really fibroma. Sutton also says that sarcoma of the ovary 
grows very rapidly ; this forms a very important clinical distinction, as 
tibromas grow very slowly. 

What is needed to settle these questions is that every solid ovarian 
tumour shall be carefully examined by a competent histologist, and its 
characters recorded with the after histories of the patients, which, un- 
less death occur soon from some other disease, will give the most impor- 
tant evidence as to the malignancy or otherwise of the tumour. 

Carcinoma of the ovary is still rarer than sarcoma ; as already stated, 
however, carcinomatous growths are not infrequently met with in cystic 
tumours. According to Olshausen the disease in 50 per cent of cases is 
bilateral, and the medullary form is the most common. The tumour 
may be as large as a man's head. 

Mr. Shattock has recorded a case of columnar-celled cancer of the 
ovary, forming a large tumour 11 inches by 5 inches ; this variety is, 
however, very rare. 

The greater number of recorded cases are clearly secondary ; but 
there is no doubt that cancer may arise primarily in the ovary. Bland 
Sutton points out that as typical adenoma is met with in the ovary 
there is reason to believe that cancer may also occur there ; for experi- 
ence shows that wherever adenoma occurs cancer may also appear. 
Positive observations have, however, been made by Steffeck and others. 

Steffeck was able, in one instance, to trace to his satisfaction the ori- 
gin of the cancer to the epithelial lining of the Graafian follicles, thus 
proving conclusively the possibility of a primary origin of the disease 



DISEASES OF THE OVARY 845 

in the ovary. Doran records a case of alveolar cancer in a girl of 
fifteen. 

Cysts of the Broad Ligament. — A considerable number of cysts, re- 
moved by ovariotomy (11 per cent according to Olshausen), are found to 
occupy one or other broad ligament. Some of these have arisen in the 
ovary and gradually invaded the broad ligament ; such cysts have prob- 
ably originated near the hilum, although not necessarily in the paro- 
ophoron. Both proliferating and dermoid cysts may be thus found in 
the broad ligament. The greater number, however, arise in the broad 
ligament, are independent of the ovary, and have distinctive characters. 
They are thin-walled and usually unilocular ; although occasionally they 
contain a few distinct cavities, and possess a loosely attached coat of 
peritoneum which can easily be separated from the true cyst wall. They 
contain a clear or opalescent watery fluid of low specific gravity (1-002 to 
1-008), which contains chlorides but no albumin. The epithelial lining 
may be columnar (when it is often ciliated), or cubical; at times the 
cyst is lined merely by a thin layer of hyaline substance. 

The oviduct is stretched over the cyst, and often is greatly elongated ; 
it does not communicate with the cyst cavity as in tubo-ovarian cysts.* 
It always remains patent. 

The ovary may be found free, or stretched and flattened against the 
cyst wall. 

The smaller and medium-sized cysts are sessile, being contained 
entirely within the broad ligament; the larger cysts often develop a 
broad pedicle easily dealt with surgically. 

Mr. Doran has carefully investigated and described an uncommon form 
of broad ligament cyst, namely, the papillary form, identical with papillary 
cysts of the ovary. He believes that they all arise from the parovarium ; 
those of the broad ligament from the vertical tubes of that body, those 
of the ovary from the prolongation of the parovarium into the hilum. 
Doran also points out that no case of proliferating cyst of the broad 
ligament has ever been described in which the ovary was not the seat 
of origin. The common broad ligament cysts, he believes, are de- 
veloped outside the p'arovarium ; so that the name parovarian cannot be 
accurately applied to them. 

Minute cysts are also often found above the tube and in the meso- 
salpinx, quite distinct from the parovarium ; also cysts may be formed 
by distension of the hydatid of Morgagni. None of these, however, 
attains such a size as to be clinically recognisable. 

Etiology. — The investigation of the origin of ovarian tumours in- 
cludes two distinct parts : (i.) The anatomical structures from which 
they arise ; (ii.) The conditions which cause them. Of the latter subject 
we know nothing; and there is much difference of opinion and un- 
certainty concerning the former. It is not worth while, in this article, 
to do more than recapitulate briefly the views of the most important 
observers. 

It is obvious that the chief difficulty lies in determining the origin 



846 SYSTEM OF GYNECOLOGY 

of the epithelial structures, which for the most part determine the char- 
acters of the cystic, papillary, and carcinomatous tumours. The connec- 
tive tissue, and such unstriped muscle as may be present, are without 
doubt developed from these elements of the ovarian stroma. 

Hyaline degeneration of blood-vessels, of abortive follicles, and of 
corpora lutea have been regarded by some authors as important factors 
in the origin of ovarian tumours; but I am unable to regard this 
passive melting of degenerating tissues as having any but a subordinate 
importance in relation to structures bearing such evidence of vigorous 
growth as do most ovarian tumours. 

With the exception of the endothelium of the vessels, the only 
epithelium that exists in the ovary is (a) the germ epithelium which 
covers the ovary at all stages, and from which (6) the epithelium of 
the Graafian follicles is probably derived, and (c) the epithelium of the 
parovarian tubes prolonged into the hilum. It is probable that observers, 
in their anxiety to find a solution for these etiological problems, have 
been led to draw their conclusions from well-defined types, and to neglect 
the numerous mixed forms which are met with {vide Introd., vol. i. of 
^this System, p. xxix). The result is that no sufficient explanation has 
been found for the occurrence of these mixed tumours. 

It is difficult to accept a different site of origin for papillomatous and 
proliferating cysts when both may be found in different compartments 
of the same tumour. And with regard to dermoids, a hypothesis which 
only accounts for the distinctively dermoid portion of a mixed cystic 
tumour is not a sufficient explanation of the origin of the whole tumour. 

Proliferating Cysts. — According to Yirchow, Rokitansky, and Rind- 
fleisch, these tumours arise in the ovarian stroma by colloid degeneration 
of the connective-tissue cells or intercellular substance. Flihrer, Klob, 
Doran, Sutton, and I may add almost all recent investigators, believe 
that they arise from Graafian follicles. Another view was advanced by 
Klebs and Waldeyer, and supported more recently by de Sinety, Malassez, 
and Flaischlen : these observers believe that they arise from certain 
tubular ingrowths of the germ epithelium found in early f(Btal ovaries, 
and associated with the development of the Graafian follicles. These 
ingrowths are known as Pfltiger's tubules. Snch evidence as there is 
to hand certainly appears to favour the view that these cysts arise in 
the Graafian follicles. 

Papillary Cysts and Tumours. — Many observers, among whom may be 
cited Olshausen, Fischel, and Doran, believe that papillary cysts arise 
from the paroophoron, some tubules of which have been repeatedly 
traced into the hilum of the ovary. On the other hand, Marchand and 
Flaischlen have satisfied themselves that these cysts also arise from 
Pflilger's tubules. The most recent writer upon the subject is Dr. Whit- 
ridge Williams, who has been able to demonstrate the origin of papillary 
cysts from : (a) germinal epithelium ; (6) the Graafian follicles. Surf ace- 
papillomas he proves to arise from the germ epithelium. He is not 
satisfied with the evidence adduced to prove that papillary cysts arise from 



DISEASES OF THE OVARY 847 

relics of the paroophoron in the hilum of the ovary, and believes that 
their origin from the epithelium of the Fallopian tube, although possi- 
ble, has yet to be demonstrated. According to the statistics of various 
operators, the proportion of papillomatous cystomata to glandular cysto- 
mata is as one to ten. When it is remembered that mixed papillary and 
proliferating cysts are by no means rare, it appears most probable that 
they arise from the same structures ; if so, the difference of their char- 
acters must depend upon some other cause. 

Dermoids. — The etiology of these tumours is quite obscure. The 
theory most generally accepted is that here, as in other parts of the 
body, they are developed from minute fragments of epiblast included in 
the ovary at a very early period of development. 

It must be remembered, however, that this ingenious and widely 
accepted view is by no means a complete explanation : the occurrence 
of mixed forms of dermoid and proliferating cysts points to a follicular 
rather than an intestinal site of origin. 

The Natural Progress of Ovarian Tumours. — The majority of ovarian 
tumours, being proliferating cysts, grow much more rapidly, in their 
advanced stages, than ovarian dermoids and the solid tumours both 
of the uterus and ovaries ; some malignant tumours excepted. Owing 
to their greater mobility, and to their often unequal increase in size, 
their position in the abdomen varies much more than that of the gravid 
uterus. 

Our knowledge of the early stages of ovarian tumours is very small ; 
for it is only occasionally, and almost by accident, that small ovarian 
tumours are discovered : they may attain a large size before the patient 
is led to seek medical advice. In the early stages the rate of growth is 
probably quite slow ; in the case of dermoids and benign solid tumours 
it is slow throughout. Rapid increase in size, to such an extent that 
it can be recognised almost from day to day, is the result of haemorrhage 
into a cyst. This is a complication almost equalling in importance the 
occurrence of concealed accidental hsemorrhage in the gravid uterus. 

If the uterus and broad ligaments are normal in position the ovary, 
enlarged by early cystic disease, lies at first in the usual position on 
the superior and posterior surface of the broad ligament on one side of 
the middle line. As it increases in bulk the tumour rarely remains in the 
posterior pelvic pouch, but rises in the direction of least resistance, and 
displacing the bowels, gradually comes into contact with the anterior 
abdominal wall ; then, if free to move laterally, it tends to assume a 
more central position. The pedicle formed by the attachment of the 
ovary to the broad ligament, while at first anterior and inferior to the 
tumour, is now as a rule directly beneath, and sometimes posterior to it ; 
the tumour lying more directly above the uterus. It is supported by the 
brim of the pelvis, causing little or no discomfort to the patient and, if 
the pedicle be long enough, no displacement of the uterus. Occasion- 
ally the tumour becomes impacted in the pelvis; either from irregularity 
of enlargement of its component cysts, or from the formation of adhesions. 



SYSTEM OF GYNECOLOGY 



Rarely the pedicle may remain anterior, and the broad ligament is 
then pulled up in front of the tumour leading to lateral displacement 
and fixation of the uterus ; and so to difficulties in diagnosis. 

Again, in the exceptional cases in which the tumour develops in the 
hilum of the ovary, it may separate the layers of peritoneum, and 
invade the broad ligament and the pelvic cellular tissue continuous 
with this. As a result the uterus becomes much displaced laterally 
and, its mobility being restricted, the diagnosis is obscured. 

Not infrequently the tumour is found to occupy the utero-vesical pouch 
of peritoneum, the uterus and broad ligaments lying retroverted behind it. 

When the tumour is once fairly upon the pelvic brim its further en- 
largement usually leads, by pressure on the abdominal walls and viscera, 
to a gradually increasing prominence of the abdomen suggestive of preg- 
nancy; the bowels being displaced upwards and laterally as in the case 
of the gravid uterus. At this stage it is usually recognised and removed ; 
but if it continue to increase the enlargement of the abdomen becomes 
very great, the diaphragm is pushed upwards, the lower part of the 
thorax becomes expanded, and severe pressure symptoms result. Cases 
are recorded in which the enlargement of the abdomen was so great that 
the head and limbs of the patient appeared to be mere appendages to 
an enormous abdominal tumour. 

In such cases of great abdominal distension, the effects of pressure 
on the organs of respiration, circulation, and digestion become so marked 
that the consequent suffering and emaciation of the patient lead to a 
characteristic facial expression ; not rarely seen in former days when, 
■owing to its great mortality, the operation of ovariotomy was usually 
postponed as long as possible. 

Doran has drawn attention to the frequency of dilatation of the 
ureters, with chronic interstitial changes in the kidneys, found in fatal 
cases after operation ; he believes that these changes are the result of 
the pressure of the tumour. 

The development of ovarian tumours does not, as a rule, interfere 
with ovulation and menstruation ; and, although both ovaries may be the 
seat of considerable tumours, so long as a portion of healthy ovarian 
tissue remains, these functions may be unaffected. Mr. Thornton has 
recorded a case of pregnancy with bilateral dermoid cystic disease; the 
relic of healthy ovarian tissue being indicated by the presence of a 
corpus luteum in the wall of one cyst. But amenorrhoea may occur 
from great deterioration of the general health, produced by the size and 
pressure effects of the tumour, or by its malignancy. 

In the case of solid tumours, which are so often bilateral, amenorrhoea, 
if present, may be due to the total destruction of Graafian follicles which 
usually occurs in these cases. 

Complications. — Cystic tumours only occasionally cause hydroperi- 
toneum, solid tumours frequently do so ; the reason for this difference 
is not known : nor is it known why solid tumours of the ovary should 
do so when similar tumours of the uterus do not. 



DISEASES OF THE OVARY 849 

If much fluid be found associated with a cystic tumour, it is most 
likely to be due, in the absence of surface or perforating papilloma or 
other extraneous causes, to leakage from one or more of the cyst cavities 
into the peritoneal sac. It is frequently due, of course, to pressure of 
the cyst upon the vena cava and great abdominal veins. In the same 
manner oedema of one or both legs may occur, and in rare cases dis- 
tension of ureters and renal pelves. 

The most frequent complication is that which leads to the formation 
of adhesions to adjacent structures ; namely, to the omentum and intes- 
tines, oviduct, uterus, bladder, and abdominal wall. Such adhesions 
may be the result of acute inflammation of the cyst leading to local 
peritonitis, a complication to be next described; or they may arise 
passively and painlessly, without any symptoms to alarm the patient, or 
even to interfere with her usual occupation. A possible explanation 
of their occurrence is that the epithelium covering the cyst wall in its 
earlier stages may be removed by friction, and a fibrinous exudation would 
then occur leading to the formation of adhesions between the adjacent 
surfaces. Such adhesions may be more or less dense and extensive, or 
merely thread-like; sometimes, especially when connected with the 
omentum, they may contain vessels so large as to become an important 
source of blood-supply to the tumour. Dermoids appear to be more 
frequently complicated by adhesions than are other tumours. Cysts of the 
ovar}^ adherent to the bladder or rectum may form communications with 
either viscus, and, in the case of dermoid cysts especial]}', with curious 
results : a lock of hair may be found protruding from the urethra or anus ; 
or bones, teeth, and other contents of these cysts maj- be evacuated. 

Tubo-ovarian cysts usually arise in a similar manner ; they are de- 
scribed later (p. 801). Adhesions are chiefly important in respect of the 
difliculties they make for the operator; in some cases, indeed, the operator 
has great difficulty in determining whether he is dealing with the parietal 
peritoneum, the cyst wall, or some adherent viscus. 

Acute Inflammation of Cysts. — This is usually a spontaneous complica- 
tion. In the pre-antiseptic period it was a common result of tapping the 
cyst for the purpose of diagnosis or treatment ; and, together with septic 
peritonitis, was not uncommonly one of the causes of the death of the 
patient. Apart from this it occurs most frequently in connection with 
conditions which interfere with the vitality of the tumour ; such are acute 
torsion of the pedicle, injury by pressure, and strangulation during labour. 
Under such conditions pyogenetic organisms appear to enter from the 
intestinal canal, and lead to suppuration. It is probable also that an 
acutely inflamed Fallopian tube becoming adherent to a cyst may infect 
it without the actual formation of a tubo-ovarian abscess. 

Torsion of the Pedicle. — This complication, when acute, is one of great 
importance ; for, unless recognised and dealt with by operation without 
delay, the danger to life is very great. A slight degree of torsion (i of 
a circle) is a common occurrence, and is probably due to the change of 
position which a small tumour undergoes as it rises from the posterior 

3 1 



850 SYSTEM OF GYNECOLOGY 

surface of the broad ligament to a position of greater mobility above the 
pelvic brim. This slight degree of torsion does not produce symptoms, 
and is probably persistent. 

Under certain conditions, such as strain of the abdominal muscles, or 
in connection with the movements of the intestines, or from unequal 
enlargement of some of the component cysts, this slight torsion becomes 
increased gradually or suddenly, with results which vary with the sud- 
denness and degree of the strangulation. In the slowly produced cases 
the circulation is gradually obstructed ; as a result, the growth of the 
tumour may be arrested. In rare cases atrophy of the twisted pedicle 
is so complete that the tumour becomes more or less separated from its 
original attachment; its vitality may then be maintained by a blood-supply 
obtained from the adherent viscera, most commonly from the omentum. 
If no such adhesions exist, the tumour lies free or almost free in the peri- 
toneal cavity, and gives rise to considerable hydroperitoneum. Acute 
torsion is afar more serious matter ; the sudden interference to the return 
of blood from the tumour frequently leads to haemorrhage" into it, and 
consequently to rapid enlargement. The tumour also becomes very 
tender, and the condition comes to simulate cases of moderately acute 
latent accidental hsemorrhage in advanced pregnancy. I have seen a 
case in which, in a young patient, torsion of the pedicle led to severe 
haemorrhage into the cyst ; as a consequence of this accident it ruptured 
into the peritoneal cavity, which was filled with blood. The symp- 
toms were very urgent. The patient, however, made an excellent 
recovery. 

In other cases strangulation of the pedicle interferes with the vitality 
of the tumour, and allows it to be rapidly invaded by septic micro- 
organisms, resulting in an acute inflammation of the cyst and peritoneum 
which necessitates immediate operation. 

Hermann W. Freund has discussed the mechanism of torsion of the 
pedicle, and suggested that a law may be laid down that right-sided 
tumours rotate to the left, and that left-sided tumours rotate to the 
right ; he admits, however, that there are many exceptions to this law. 
Professor A. K. Simpson has also illustrated the same law by three 
cases. Freund quotes ten cases ; in six only was the pedicle twisted, in 
four the rotation was right, and in two left sided. Of the four which 
rotated to the right, two were right tumours, and two left ; and of the 
two which rotated to the left, one was a right, the other a left tumour. 
Out of sixty-six cases of ovariotomy at St. Bartholomew's Hospital, 
between August 1892 and October 1894, there were fifteen cases of 
torsion of the pedicle of ovarian cysts, and one of a broad ligament cyst. 
Of ten left-sided tumours, six were twisted in the opposite direction to 
the movements of the hands of a watch, that is, from right to left ; and 
four in the same direction, that is, from left to right. Of five right-sided 
tumours three were twisted from left to right, and two from right to 
left. These numbers are not large enough to decide the question of 
Freund's '' law " ; but they suggest that the direction of rotation does 



DISEASES OF THE OVARY 851 

not present a constant relation to the side to which the tumour is 
attached. 

Incarceration of Ovarian Tumours in the Pelvis. — This is a rare com- 
plication ; but it is found occasionally in the case of tumours which invade 
the broad ligament, and which having no pedicle are greatly restricted 
in their mobility. Still more rarely a pedunculated ovarian tumour may 
become incarcerated in the retro-uterine pouch of the pelvic peritoneum, 
giving rise to retention of urine ; as in the far less rare cases of incarcera- 
tion of uterine fibroids or extra-uterine gestation cysts. In St. Bartholo- 
mew's Hospital Museum is a rare specimen (No. 2951 c) of a dermoid 
cyst adherent to the uterus, and causing retention of mine. This was 
unrelieved, owing to the common mistake of not recognising that con- 
stant dribbling of urine following retention is a symptom of extreme 
distension of the bladder. 

Rupture of Cystic Tumours. — This occurs in three forms : (a) Eupture 
of a thin-walled unilocular cyst, leading to a sudden disappearance of the 
tumour, and the presence of free fluid in the peritoneal cavity. In these 
cases the cyst usually fills again. (6) The rupture of one or more loculi 
of a multilocular cyst, leading to constant leakage into the peritoneum, 
and thus to the presence of a cystic tumour with free fluid, (c) The 
perforation or rupture of a cyst, or parts of a cyst containing papillomas, 
followed by the detachment and escape of particles, and the spreading 
of the growth over adjacent parts. The rupture may occur spontaneously, 
or during a medical examination, or in consequence of injuries, such as 
falls or blows. If the contents of the cyst are aseptic, as is usually 
the case, the immediate effects are slight. Unless hcemorrhage occur 
there is little pain or shock, as a rule ; although sometimes these are 
marked. The tumour of course disappears, and occasionally does not 
reappear. The fluid, if thin, is rapidly absorbed by the peritoneum, and 
excreted by the kidneys ; a condition of polyuria persisting for some 
days. If the fluid is viscid it accumulates in the peritoneal cavity, the 
cyst continually leaking ; gradually it occupies all the peritoneal spaces 
between the bowels, and even the more distant parts between the liver 
and the diaphragm, so that it becomes very difficult to remove it entirely 
at the operation. 

A case of infection of the peritoneum with dermoid growths after 
rupture of the primary tumour has already been mentioned ; and the 
spreading of papillomatous growths in this way is well known. Such 
secondary growths are benign ; and after removal of the main tumour, 
although the infected peritoneum is very imperfectly dealt with, spread- 
ing ceases, and the patient makes a permanent recovery. 

Pregnancy and Labour complicated by Ovarian Tumours. — Ovarian 
tumours form a very important complication of pregnancy and labour. 
The difficulty during pregnancy is in the diagnosis, not in the treatment : 
experience shows that ovarian tumours may be safely dealt with at any 
period of pregnancy ; and as a general principle should be so dealt with. 

Labour may be complicated by the presence of an ovarian tumour in 



852 SYSTEM OF GYNECOLOGY 

the abdomen or in the pelvis. In the abdomen tumours may be of con- 
siderable size without doing much harm ; but if even a small tumour 
occupy the utero-sacral pouch of the pelvis it will cause obstruction, 
and must be dealt with. Most of these are cystic tumours ; but a case 
of fibroma of the ovary has been recorded by myself which during labour 
simulated the head of a second extra-uterine foetus. 

Cystic tumours have been driven down by the advancing foetal head, 
and have burst through the posterior vaginal wall, so that the tumour 
has been spontaneously delivered before the foetus. 

Sometimes it is possible, under deep ansestliesia, to raise the tumour 
above the pelvic brim, and so out of the way ; especially during the 
earlier stages of labour. 

When the obstructing tumour is a thin-walled cyst, simple puncture 
through the posterior vaginal wall will be the best method of dealing 
with it for the time. When this is not successful, owing to its multi- 
locular character, or when the tumour is solid, there can be no doubt 
that abdominal section, followed, in certain cases, by the Csesarean section 
and removal of the tumour, is preferable to dragging the foetus past the 
obstructing mass. When this latter course is adopted, so much injury 
is done to the tumour, as a rule, that afterwards it becomes acutely in- 
flamed, and the patient is placed in a state of very great danger. 

Diagnosis. — Ovarian and Broad Ligament Tumours. — The diagnosis 
of ovarian tumours rests upon the recognition of their physical characters, 
for there are no symptoms of diagnostic value; the abdominal enlarge- 
ment which attracts the patient's attention is generally her only com- 
plaint. Still this very absence of symptoms, coupled with progressive 
enlargement of the abdomen, is of value in the investigation of the case ; 
and in the endeavour to set aside other abdominal diseases. It does not 
require a very large experience to convince us that, as Matthews Duncan 
said, until the abdomen is opened and the tumour exposed, the diagnosis 
of such cases is not one of scientific precision, but rather of a great proba- 
bility ; amounting, no doubt, in very many cases to practical certainty. 
This fact, coupled with personal recollection of mistakes, will make the 
physician cautious even in cases that appear to be simple, and still more 
so when they present unusual characters. In the large majority of 
cases, so long as the patient's health is not seriously affected by this or 
other causes, and the uterus itself is healthy, menstruation and ovulation 
continue unaffected by the disease. Interference with ovulation is of 
much more frequent occurrence in the case of the rare solid tumours than 
it is in cystic tumours. Too much stress has been laid by some authors 
on the presence of a tendency to amenorrhoea as a symptom of ovarian 
cystoma. It is far more correct to say that the absence of amenorrhoea 
and other menstrual disorders is the symptom of importance. That is 
to say, that in a woman having an abdominal tumour of pelvic origin, if 
the menstrual function remain normal it is of diagnostic value in favour of 
ovarian tumour; and as a symptom it must be considered as of equal value 
to the amenorrhoea of pregnancy and the menorrhagia of uterine fibroids. 



DISEASES OF THE OVARY 853 

Of the last 118 consecutive cases operated on in " Martha " ward at 
St. Bartholomew's Hospital up to March 1895 — 20 cases were in patients 
either before puberty or after the menopause. Of the remaining 98 — 
in 73 menstruation was normal ; in 7 there was amenorrhoea for short 
periods — 3-12 months ; in 3 the menstrual flow was lessened in quantity ; 
in 3 menorrhagia was present ; in 4 menstruation was increased in quan- 
tity, but the health was not thereby affected; in 8 menstruation was 
quite irregular as regards both time and quantity. These figures show 
that in about 75 per cent of cases of ovarian tumour menstruation con- 
tinues unaltered during the twelve months preceding the diagnosis of 
the tumour ; and that in the remaining cases increased loss is nearly as 
frequent as diminished loss. But in these cases of altered menstrua- 
tion the possibility of a uterine cause must be borne in mind before the 
disturbance is assigned to the ovarian tumour. 

Pain is an unusual symptom in cases uncomplicated by impaction, 
inflammation, or strangulation ; and the pressure effects are usually not 
attended by much discomfort until the tumour has attained a considera- 
ble size. In rare cases the pressure appears to be the immediate cause 
of procidentia uteri, even in nulliparous women. I have seen two such 
cases in neither of which was the tumour impacted. 

Matthews Duncan, in his Clinical Lectures, says with regard to the 
diagnosis of ovarian cystoma: ''You get no aid from symptoms. Fre- 
quently there are and have been no symptoms ; the case comes before 
you solely on account of size ; or you may accidentally discover the 
tumour. Sometimes there are symptoms which may be described as 
resembling those of advancing pregnancy; only instead of the mam- 
mary and clavicular fat increasing as they generally do in pregnancy, 
you have them generally diminishing. Sometimes you have disturb- 
ance of menstruation. Sometimes you have a history of severe pain in 
the womb, or in one or the other ovarian region. Sometimes you are 
told the swelling began on one side. But all these indications vary 
much, and however they may be combined they form no basis for a 
diagnosis." 

The first stage in the diagnosis of ovarian tumour is obviously the 
recognition of an abdominal or pelvic tumour. The second is the identi- 
fication of the tumour as ovarian, partly by the recognition of its physical 
characters, partly by exclusion of other kinds of tumour. Both of these 
stages present difficulties, sometimes so great that nothing short of an 
exploratory opening of the abdomen is sufficient to determine the diag- 
nosis : and there are cases of such obscurity that even this operation, 
in the hands of an experienced operator, followed by more or less com- 
plete evacuation of the contents of some cavity, may prove insufficient 
to determine the exact nature and origin of the tumour. 

In the first place, let it be certain that the bladder is empty, using 
the catheter if there be any doubt on this point. It would be easy to 
quote examples of mistakes made, not by beginners only, from neglect 
of this simple precaution. Almost equally important is the clearing 



854 SYSTEM OF GYNECOLOGY 

out of the bowels ; for faecal masses are not infrequently mistaken for 
abdominal tumours. Next, and of first-rate importance, let it be always 
assumed that a woman, who is of the child-bearing age, and whose men- 
struation has been absent for a period of one to twelve months, is pregnant 
until absolute proof to the contrary be obtained. Mistakes in connection 
with pregnancy are the most common and the least excusable of any. 
How often do we meet with cases in which a simple normal uncompli- 
cated pregnancy is diagnosed to be an ovarian cyst ; and how often is a 
woman or girl suspected of pregnancy, sometimes even accused of it, 
when her only misfortune is an ovarian tumour ! 

The diagnosis of pregnancy, intra- or extra-uterine, when the foetus 
is dead, of pregnancy with hydramnion or complicated with ovarian or 
other tumours of considerable size, is often difficult enough ; but that 
of normal pregnancy, advanced to such a size as to form an abdominal 
tumour, is simple if the examination be systematic. This is not the 
place to go fully into the question of the diagnosis of pregnancy ; but 
it may be mentioned that the easiest way of diagnosing this condition 
beyond the fifth month (that is, the fundus above the navel) is by pal- 
pation of the abdomen, when the hand may recognise parts of the foetus 
floating in fluid, and some of them may present spontaneous movements. 
Next, in every case of obscurity, let the patient be put under an 
anaesthetic ; and when muscular relaxation is complete, repeat the 
examination of the abdomen and pelvis. The general condition of the 
abdomen, fluctuation, and the area, site, and limits of the supposed 
tumour become far clearer when the abdomen is well relaxed ; hence the 
aid of an anaesthetic is often invaluable. 

Recognition ofAhdominal Tumour. — This involves the recollection and 
the exclusion of conditions which simulate abdominal tumours : namely, 
enlargement of the abdomen by accumulation of fat in its walls and 
within it ; distension by flatulent bowel and by faecal masses ; ascites ; 
and masses of bowel matted together by adhesions, with or without much 
fluid effusion. Of these, certain cases of localised hydroperitoneum and 
cases of chronic peritonitis are apt to give rise to the greatest difficulties 
of diagnosis. 

An ovarian tumour has usually a well-defined outline above and at 
the sides ; it is often irregular, not rarely nearly spherical ; usually there 
is a distinct feeling of fluid within it, with well-marked fluctuation in 
parts, if not in the whole mass. 

The presence of fluctuation in all directions, and over the whole area 
of an abdominal tumour, proves the continuity of the fluid and the prac- 
tically unilocular nature of the cyst ; but this may be closely simulated 
in some cases of solid tumour in front of which lies a layer of free fluid. 

Hard masses felt in an otherwise cystic tumour usually indicate 
secondary cysts, which when small are usually very tense and feel solid ; 
they have no tendency to ballottement, and do not present spontaneous 
movements, as do parts of a foetus in utero. There is dulness on per- 
cussion over its whole surface, except perhaps at the margins where 



DISEASES OF THE OVARY 855 

bowel distended with gas may overlap it, or by contact give a false 
impression of resonance. 

No pain is given by palpation unless strangulation or inflammation 
of the tumour, or considerable haemorrhage into it, have occurred. An 
ovarian tumour is usually dumb, no souffle being audible as it frequently 
is in all kinds of uterine tumour; but pulsation sounds communi- 
cated from the great abdominal vessels may be heard and are of no 
importance. 

The recognition of these features will enable us to exclude all the 
ordinary conditions simulating abdominal tumours. There is no defined 
tumour, dull on percussion, produced by accumulation of fat, or by 
distended flatulent bowels ; whilst faecal masses are more likely to be 
overlooked than to be mistaken for ovarian tumours : I have already re- 
ferred to the paramount necessity of clearing the bowels and emptying 
the bladder before attempting to make a diagnosis. 

Hydroperitoneum (Ascites). — It is only under exceptional circum- 
stances that a passive hydroperitoneum gives rise to difficulty in diag- 
nosis in relation to ovarian tumours. Hydroperitoneum may be present 
with any form of abdominal tumour ; or if one or more parts of a cystic 
tumour having burst continue to leak into the peritoneal cavity, a con- 
dition of tumour with free fluid may be produced. In such cases the 
tumour will usually be felt, and the presence of free fluid ascertained 
with equal certainty. 

But the most puzzling and unexpected cases are those in which a 
passive serous effusion takes place, perhaps to the extent of several pints ; 
and the fluid, instead of sinking to the most dependent parts, is con- 
fined to the centre of the abdomen, in a kind of sac formed by the 
coils of intestine tightly pressed together or slightly adherent. The 
physical characters of such a collection are not distinguishable from those 
of a thin-walled unilocular cyst. Two such cases occurred in succession 
in my ov/n practice, and both were mistaken for ovarian cysts. 

Collections of fluid in the peritoneal cavity in connection with chronic 
tubercular peritonitis, are frequently met Y/itli ; but as a rule a " tumour " 
thus formed will be resonant on percussion over a large part of its area, 
and will be accompanied by other signs of evident illness ; the tempera- 
ture will usually be found distinctly raised at night — a symptom of the 
highest importance. 

The last class of false abdominal tumours are those formed from 
matted coils of intestine and omentum, with more or less fluid in the 
interstices, whether serum or pus. Such masses are produced in connec- 
tion with inflammations of the vermiform appendix, or of the ovaries 
and oviducts ; and these, from their close proximity and frequent adhe- 
sion to the uterus, are liable to be mistaken for uterine fibroids. 

Diagnosis of Pelvic Tumours. — To recognise the presence of a pelvic 
tumour, and still more to be able to identify its nature, is a far more 
difficult matter than in the case of most abdominal tumours. It requires 
not only an intimate knowledge of the subject, but a greater experience 



856 SYSTEM OF GYNECOLOGY 

in the practical application of that knowledge than most practitioners 
are able to obtain. We have here first to deal with the recognition of 
a tumour. 

A pelvic tumour from simple anatomical reasons is most likely to 
occupy that part of the pelvic cavity which lies above and behind the 
uterus and broad ligaments. This space, in health, is occupied by coils 
of small intestine, which are very easily displaced from it ; and it varies 
in size with the varying distension of the bladder and rectum. Normally 
the utero-vesical pouch is merely a linear cavity, the uterus and broad 
ligaments resting directly on the bladder. This linear cavity is at once 
opened up and admits coils of small intestine, when the uterus and 
broad ligaments are retro verted ; and, under such conditions, is of course 
most open when the bladder is empty. A pelvic tumour can only be 
recognised in either of these cavities by a bimanual examination ; and 
the emptying of bladder and rectum, and the use of an anaesthetic, are 
of the greatest importance in this examination, as in the case of ab- 
dominal tumours. 

A tumour may be so small as not to lead to any appreciable displace- 
ment of the uterus ; such are the rare tumours of the round ligaments 
of the uterus, the common small enlargement of the ovaries and tubes, 
and small uterine fibroids. But as a rule the tumour, according to its 
position and size, will be found to displace the uterus more or less to the 
opposite side if lateral to the uterus ; forwards if behind it ; backwards 
if in front of it. 

The first suspicion of the presence of a pelvic tumour usually arises 
during a vaginal examination. The cervix is first identified either in a 
nearly normal position ♦or displaced laterally, anteriorly, posteriorly, 
upwards or downwards ; and careful palpation reveals a convex swelling 
behind, in front, or on one or on both sides of it. The next stage is to 
ascertain that the convex swelling is part of the surface of a more or less 
spherical tumour, not something simulating one. The conditions most 
likely to simulate a tumour are — (i.) the body of the uterus felt as it 
normally is through the anterior fornix ; or felt more readily than nor- 
mally because anteflexed or because of an increase of its normal ante- 
version ; or felt on one side of the cervix from lateral displacement ; or 
through the posterior fornix from retroversion or retroflexion : (ii.) the 
bladder more or less distended, or the rectum loaded with faeces : (iii.) 
some adhesions intra- or extraperitoneal. The diagnosis of the second 
states is so easily determined by the use of the catheter, and by digital 
examination of the rectum, that it is not necessary to allude to it further ; 
but adhesions, the result of perimetritis, or parametritis, require care- 
ful examination. In the first place, simple adhesions usually draw the 
uterus to the affected side, and by bimanual examination are found to 
have little thickness ; the two hands may meet, and the absence of a 
"tumour" is then clear. If there be much effusion of pus, blood, or 
serum, either into the cellular tissue or peritoneum, a definite tumour 
is formed and the uterus is displaced from its normal position. If, by a 



DISEASES OF THE OVARY 857 

bimanual examination, the abdominal hand finds a convex surface project- 
ing into or above the pelvic inlet, and corresponding with that discovered 
by the finger in the vagina, the presence of a " tumour" is then clear; and 
we proceed to endeavour to ascertain its nature, and in the first place to 
determine that it is not the body of the uterus enlarged by pregnancy, 
or by such diseases as produce uniform increase in size — such as certain 
fibroids, cancer of the body, pyometra, heematometra, and hydrometra. 

Here, as in the case of abdominal tumours, to set aside pregnancy 
is of the first importance, a task by no means always easy even to the 
experienced physician ; and it is not rare to find pregnancy at any stage 
complicated by the presence of a tumour. 

The diagnosis of the pathological enlargements of the body of the 
uterus is given elsewhere, the difficult bimanual examination being of 
the greatest importance. 

If pregnancy is certainly set aside, the uterine sound passed up to 
the fundus is of the greatest value ; for it not only determines the length 
of the uterine cavity, a detail of great value in distinguishing uterine 
from non-uterine pelvic and abdominal tumours, but it identifies the 
relative positions of tumours lying close to it in cases in which a 
bimanual examination has failed to do so. The difficulties which are 
met with in passing the sound to the fundus, however, lead sometimes 
to mistakes in both these particulars, and to incorrect inferences. 

Having now excluded or recognised enlargement of the body of the 
uterus, and determined that there is a tumour adjacent to it, and what 
their relative positions are, we proceed to consider, one by one, the 
different forms of tumour that may be present. 

The consideration of such tumours shows how necessary it is to have 
a wide knowledge of the diseases themselves, and of their symptoms and 
physical characters, as well as a large experience in practical diagnosis, 
to enable the practitioner to arrive at an accurate conclusion ; and every 
one knows how often the diagnosis, even by men of large experience, is 
imperfect, or indeed sometimes quite mistaken. 

Before proceeding further it will be well to return to abdominal 
tumours that we may make a preliminary selection of them, as both 
pelvic and abdominal tumours have many points in common ; and the 
differential diagnosis, when once the tumour is ascertained to have a 
pelvic origin, proceeds on almost identical lines. Also abdominal 
tumours can often be felt on vaginal examination to lie partially within 
the pelvis ; eyen sometimes when they arise from organs so distant as 
the kidneys and spleen. We must, therefore, bear in mind that while 
tumours contained in the pelvis are almost invariably of pelvic origin, 
abdominal tumours which lie entirely above the brim of the pelvis may 
have originated either in the pelvic or in the abdominal organs; and that 
tumours that lie partly in the abdomen and partly in the pelvis, while 
usually of pelvic origin, may have arisen primarily in an abdominal 
organ, and have descended later into the pelvis. 

Diagnosis of the Site of Origin of an Abdominal Tumour. — It is not nee- 



858 SYSTEM OF GYNECOLOGY 

essary here to discuss all possible sites for every variety of abdominal 
tumour. We begin with the assumption that the tumour before us is so 
situated in the abdominal cavity that a pelvic connection is not altogether 
improbable ; thus we exclude at once such tumours as those of the gall- 
bladder and pylorus. Now such a tumour may arise in the pelvic, renal, 
splenic, hepatic, and central (mesenteric and omental) regions. A 
tumour of pelvic origin can be traced down to the pelvic brim, as the 
physician stands by the side of the patient and looks towards her feet, 
with his hands placed on her abdomen and his fingers directed down- 
wards to the pelvis ; there will be no area of resonance between the 
prominent part of the abdominal tumour and the pelvic brim, because 
the tumour, as it arose out of the pelvis, will have displaced the intes- 
tine in much the same way as a gravid uterus does, and will lie in con- 
tact with the abdominal wall. A small tumour of pelvic origin lying 
above the pelvic brim is usually very freely movable, and may therefore 
be found sometimes on one side, at other times on the other ; but if it 
be found constantly on one side, this will indicate with great probability 
the side from which it sprang. 

Large tumours, having to accommodate themselves with greater 
difficulty to the abdominal cavity, are more centrally placed, and their 
mobility is much more restricted. 

Many tumours arising from the kidneys are easily identified as to 
their origin. A renal tumour is almost confined to one-half of the 
abdominal cavity, and it can be traced by bimanual palpation (one hand 
being on the abdominal surface of the tumour, the other on the loin) 
right into the region of the kidney. 

The only tumours of the liver likely to be mistaken for ovarian are 
hydatids. They are notoriously deceptive ; but as a rule their connec- 
tion with the liver can be traced, and an area of resonance between the 
tumour and the pelvis can be detected. 

A large fluctuating hydronephrosis, extending well across the middle 
line of the abdomen and so far down into the cavity of the pelvis that it 
can be reached by a vaginal examination, may very easily be mistaken 
for an ovarian cyst. 

The spleen may become dislocated and greatly enlarged, and sinking 
down to the pelvis be mistaken for an ovarian tumour. Mr. Meredith 
operated on such a case, which he and the writer believed to be a solid 
ovarian tumour. It occupied the utero-vesical pouch, where it was easily 
recognised ; and it rose nearly to the navel. On opening the abdomen 
a black mass was exposed, which proved to be the spleen. It was left 
untouched in this position, the patient being in excellent health. The 
cause of the dislocation appeared to have been a violent fall from a dog- 
cart. 

Tumours arising in the central abdominal regions are often very 
puzzling ; the presence of a well-defined area of resonant bowel between 
them and the pelvis, and the absence of any definite connection with the 
pelvis, though not sufficient for diagnosis, is sufficient to distinguish 



DISEASES OF THE OVARY 859 

tliem, with rare exceptions, from ovarian tumours. It must be borne in 
mind, however, that in exceptional cases a tumour of pelvic origin may 
lose its pelvic attachment, and be fed by the blood-vessels of its omental 
and other adhesions ; or may have such a long pedicle that it becomes 
entirely abdominal in position. 

Diagnosis of Ovarian and Broad Ligament Tumours from other Pelvic 
and Abdominal Tumours. — It has already been pointed out that the 
diagnosis of ovarian and broad ligament tumours is made by a process of 
exclusion of other forms of tumour, as well as by the recognition of the 
ph^^sical characters of the tumour under observation ; characters which 
are not always so distinctive as to enable us to do more than arrive at 
an opinion of probability, but not of certainty : and it not infrequently 
happens that the complete diagnosis is not made until the tumour has 
been exposed to sight and touch by an exploratory oj^eration. It is 
obvious that under these circumstances it is not only necessary to know 
the varieties, the symptoms, and the physical characters of ovarian and 
broad ligament tumours, but that it is also of no less importance to know 
the varieties, the symptoms, and the physical characters of all tumours 
which may occupy the same region, or be otherwise mistaken for them. 
It is not desirable within the limits of this article to enter on this part 
of the subject, but I will refer for the last time to the conditions which 
too frequently lead to easily preventable mistakes in diagnosis. Of these 
the most common are a normal pregnancy, a distended bladder, flatulent 
distension of the bowels, a fat abdominal wall, and, less frequently, 
simple ascites. Such mistakes are the result of ignorance of first 
principles, or of carelessness in examination ; they are not to be prevented 
by other means than knowledge, due care, and systematic examination. 
Direct Recognition of the Physical Characters of Uncomplicated Ovarian 
and Broad Ligament Tumours. — The large majority of all these tumours 
are cystic. In the rare cases of solid ovarian tumours the diagnosis prac- 
tically lies between them and uterine fibroids, either sessile or peduncu- 
lated, projecting from the peritoneal surface of the uterus ; these are 
common enough. The direct diagnosis of the presence or absence of 
uterine fibroids by bimanual examination is not usually dif&cult. If 
hydroperitoneum be found complicating a solid tumour of pelvic origin 
the tumour may be assumed to be ovarian. 

Cystic ovarian or broad ligament tumours, when uncomplicated by 
adhesions or impaction, are easily recognised by their well-defined 
spherical shape and obvious elasticity ; but they have to be distinguished 
from cystic dilatation of the oviducts, and this is frequently not by any 
means easy, unless the ovary on the same side can be defined by rectal 
examination (the uterus, if necessary, being drawn down with an appro- 
priate instrument). The close proximity of the two organs and the great 
similarity in shape and other characters of the cysts formed in them, 
make this differential diagnosis often uncertain. The importance of it 
is, however, of the highest degree if extra-uterine gestation be suspected ; 
for though the possibility of a primary ovarian pregnancy cannot be 



86o SYSTEM OF GYNECOLOGY 

denied, experience amply shows that if the tumour can be proved to 
be ovarian, it may safely be assumed not to be the seat of a gestation 
sac. Cysts invading the broad ligaments, or originating in them, are 
more obviously lateral, and displace the uterus as they increase in size ; 
they are also less freely movable, and not rarely, as they grow, they in- 
sinuate themselves beneath the peritoneum, beyond the limits of the broad 
ligaments in the pelvic and abdominal cavities. The essential points, then, 
in the diagnosis of a pelvic ovarian t amour are the discovery by bimanual 
examination of a spherical cystic tumour ; or, much more rarely, of a 
solid one, which, although found to lie in close relation to the uterus, is 
ascertained not to be uterine. It is, of course, in cases where the tumour 
and the uterus are closely pressed together, or are adherent, that mistakes 
are so easily made : but the absence of menorrhagia and of lengthening 
of the uterine cavity should put us on our guard ; and the advantage 
of an examination under an anaesthetic, which completely relaxes the 
muscles, is very great. After consideration of the preceding details, 
it will be seen that Matthews Duncan's teaching fairly represents the 
difficulties of diagnosis : — 

" I have said it is a nearly safe rude guess that you have an ovarian 
dropsy when you find a quickly grown cystic-feeling tumour in the belly 
of a woman, and this rude diagnosis is nearly safe because of the com- 
parative frequency of ovarian dropsy as the cause of such tumours. . . . 
Every case demands careful investigation, for a good diagnosis is diffi- 
cult, or, in other words, errors are frequent." 

Diagnosis of Strangulation of the Pedicle. — The symptoms of this com- 
plication vary as the arrest of the circulation in the pedicle is sudden or 
gradual ; complete or incomplete. 

In the acute cases there is sudden and severe pain in the region of 
the pedicle, often accompanied by faintness, vomiting, and collapse. 
The abdomen is tender, and becomes much more so, and is distended by 
tympanitic bowel as well as by the tumour. Such symptoms occurring in 
a woman known to have a tumour in the pelvis or abdomen are sufficient 
indication both for diagnosis and treatment ; and the latter should be 
removal without delay. To wait for the subsidence of the symptoms of 
peritonitis is usually to wait until it is too late. Day by day, in such a 
case, the symptoms will be getting more grave ; and careful observation 
of the tumour will often lead to the recognition of an unmistakable 
increase in size (distinguishable from conditions simulating this, such as 
adhesions of coils of intestine and inflammatory exudation round it). 
Such enlargement, noticeable from one day to another, is the result 
usually of haemorrhage into the cyst, or sometimes of the rapid formation 
of pus in it ; the differential diagnosis between the two is not at all easy, 
but it is of no real importance, as the treatment is the same in both 
cases — immediate removal. 

A temperature constantly below the normal is in favour of haemor- 
rhage ; inflammation of the tumour, which usually results from acute 
strangulation, is attended by some degree of fever. 



DISEASES OF THE OVARY 86 1 

The success which follows operative treatment in such cases, when 
correctly diagnosed, marks one of the great advances in abdominal sur- 
gery in the last few years. In less acute cases the symptoms arise more 
gradually ; and there is not the imperative need for immediate removal : 
yet removal without undue delay is the best treatment, for adhesions, 
when recent, can be separated without difficulty ; but when they become 
fibrous and tough great difficulties may be incurred in the separation, and 
great injury may be done to important viscera, especially to the intestines, 
which may lead to serious complications after the patient's recovery. 

Adhesions of the omentum, even when extensive, are surgically of 
little importance. A curious condition of varicose vessels in the 
omentum is sometimes met with resembling a bundle of worms, lying 
immediately beneath the abdominal wall, on the surface of the tumour. 

Inflammation of the Ovaries. — It is necessary to bear in mind 
that inflammation of the ovaries is intimately associated with and usually 
forms one part of a widely extended inflammatory process involving the 
uterus, the oviducts, and the pelvic peritoneum and cellular tissue ; and 
that to describe apart the inflammation of any one of these structures is 
likely to lead to narrow and erroneous views, not in pathology only but 
also in diagnosis and treatment. 

Inflammation of the ovaries may fairly be described as occurring 
in two forms, which are frequently though not necessarily combined; 
namely, inflammation of the surface (perioophoritis), and inflammation 
of the organ itself (oophoritis). 

Perioophoritis, resulting in adhesions to adjacent parts, is commonly 
met with. It is a more or less important part of that disease — great in 
importance and frequency, though often slight in severity — which is 
known as perimetritis (that is, the pelvic peritonitis of women). 

The adhesions may be mere threads uniting the ovary to the omentum 
or other adjacent parts ; or a glueing of part of its surface to the mouth 
of the oviduct ; or they may be so extensive as to lead to some difficulty 
in finding and disembedding the ovary in the course of an operation or 
post-mortem examination. Perioophoritis may arise as an extension of 
oophoritis, but this is probably not the most frequent course : it is more 
commonly part of a perimetritis arising by infection of the pelvic peri- 
toneum through the open mouth of the oviduct, or through lymph 
channels or wounds communicating with the peritoneal sac ; or again, 
the result of an effusion of blood into the peritoneal cavity (hsematocele). 

In some cases the disease may not be of pelvic origin, but only part 
of a general peritonitis of septic or tubercular origin. Perioophoritis has 
already been referred to as a complication of ovarian tumours. 

The disease perimetritis is described in the article on " Pelvic Inflam- 
mation " ; here I have only to indicate certain points which affect the 
functions of the ovary and the health of the individual. 

The chief function of the ovary, apart from any supposed '^ internal 
secretion," is to provide a sight for the maintenance and perfect develop- 
ment of healthy ova, to allow their extrusion under certain not well 



862 SYSTEM OF GYNECOLOGY 



ascertained conditions, and to discharge tliem in a position Tv'iiei.e tliey 
may securely find entry into the mouth of the oviduct. It is obvious, on 
the other hand, that perioophoritis will be likely to interfere with the 
extrusion of the ovum and its passage into the oviduct. For, in the first 
place, it is accompanied by a thickening and induration of the surface of 
the ovary, which interfere with or prevent the rupture of the Graafian 
follicles. Thus it is probable that the rupture may be prevented by the 
close adherence of that part of the ovary which contains the follicle to 
some neighbouring structure. Or the ovum, having been extruded, may 
be prevented from passing into the oviduct by adhesions fixing the fim- 
briated orifice to another part of the ovary. 

Adhesions are a fertile source of suffering, especially if they restrict 
the free mobility of the ovary, and fix it in a position where it is subject 
to undue pressure. The patient probably suffers pain, localised more or 
less distinctly at the pelvic brim, and extending down the thigh of the 
affected side. Also during the days preceding and at the commencement 
of the menstrual flow, a tender, fixed ovary becomes far more tender 
owing to its vascular engorgement at this time, and perhaps to the further 
increased tension of the organ already confined by adhesions. 

It is believed by many authors that an inflammation beginning as a 
perioophoritis may extend beyond the surface into the substance of the 
ovary, and produce induration and other changes in the superficial stroma, 
which made lead to dropsy of the follicles and to haemorrhage with con- 
sequent degeneration of the ova. Such a condition is known as '^ cystic 
ovaritis." Examination of some enlarged ovaries affected with oopho- 
ritis certainly appears to favour the view that fibrosis may arise on the 
surface and gradually invade the deeper tissues ; but before we can feel 
sure of the interpretation of the details observed, we must attain an 
accurate knowledge of the normal ovarian structure at different periods 
of adult life. 

Oophoritis, in its well-marked forms, like perioophoritis, is part of a 
more general disease. Even where there are no signs of inflammation 
of contiguous structures, and where this appears to be the single disease 
from which the patient is suffering, evidence can often be obtained that 
it arose in connection with some such disease as gonorrhoea ; or there 
may be evidence of tubercle elsewhere ; or again, it may be the only 
important relict of an extensive septic inflammation. 

Oophoritis in its most acute forms is met with in connection with 
acute pelvic or general septic inflammation — the infection having gained 
admittance through lesions of the vagina and uterus arising during 
labour, abortion, surgical operation, or examination or accidental injury 
of the parts. If the ovary were previously the seat of cystic disease, 
or of tubercle, it may become further infected and inflamed by the pas- 
sage of septic organisms from the bowel through the cyst wall. 

The continuity of structure of the stroma and the blood and lymph- 
vessels, of the ovaries and broad ligaments, readily explains the extension 
of inflammation of the vagina or uterus along the parametritic connective 



DISEASES OF THE OVARY 863 

tissue to the ovary. This no doubt occurs; probably it is the most 
frequent course ; but in many cases such an extension cannot be traced. 

It is commonly held that oophoritis is the result of an extension 
of inflammation from the uterus along the oviduct, the infective mate- 
rial escaping from the open mouth of the tube on the surface of the 
ovary. This supposition does explain the occurrence of perioojDhoritis ; 
it is well known that escape of pus from a pyosalpinx does produce a 
localised or general peritonitis ; and it may be the fact that septic mat- 
ter may gain access to the interior of the ovary through an open and 
ruptured Graafian follicle, if not through the lymph spaces on the 
surface. Wertheim's (36) investigations appear to prove conclusively 
that gonococci may pass directly through the wall of the Fallopian tube 
into the substance of an adlierent ovary, or into the broad ligament, 
and so set up inflammation. 

The most acute forms of oophoritis are those resulting from septic 
infection in connection with child-birth, abortion, and surgical proced- 
ures. In the fatal cases the ovary may be much enlarged, soft, and 
sloughing ; or in less severe cases small extravasations of blood or pus 
may be seen on section in the stroma or follicles ; in either case the 
uterus, oviducts, and broad ligament will be found in a condition simi- 
lar to that of the ovary. In cases where death has occurred within a 
few days of the infection, little loculi of pus can often be found in the 
vessels and connective tissue, close to the side of the uterus as well as 
in the uterine walls ; and the mucous membrane of the oviducts will be 
found acutely inflamed. Evidence of a wide-spread septic process is 
also to be found in more distant structures. 

In cases of acute but localised septic oophoritis the early changes 
are less certainly known ; though, as a result of the surgical procedure 
now often successfully adopted, the later stages are becoming more 
familiar to us. The minute foci of suppuration either disappear by 
resolution, or they extend and coalesce, and may form an abscess of 
considerable size — the size of a hen's Qgg or larger. The very large 
abscesses of the ovary are probably the result of suppuration of cysts. 
Such suppurating ovaries become adherent to neighbouring structures, 
and if the walls are very thick the abscess may remain quiescent; 
nevertheless it may produce a chronic state of ill-health and suffering, 
or it may open into the bowel ; indeed, unless it be thus emptied and 
the cavity enabled to shrink up and ultimately to close, the 'patient 
passes into the same state of chronic ill-health as that produced by an 
unruptured abscess, and under such circumstances, unless the patient 
can be relieved by operation, she may gradually lose ground and finally 
die from exhaustion and the other consequences of prolonged suppuration. 

Oophoritis Serosa. — There is quite another form of what may be 
called inflammation of the ovary of an exceedingly chronic kind — 
chronic in development, very chronic in duration, but in the majority of 
cases curable under proper management. It is met with in cases of pro- 
longed ill-health in which no local cause can be recognised. It follows 



864 SYSTEM OF GYNECOLOGY 

some fevers, it has occurred in two cases of mumps under my own care, 
it is met with in women married for some years who have not become 
pregnant : in some of these cases the cause of the sterility may be a 
passive gonorrhoea! infection ; indeed, this form of oophoritis appears 
to be that most frequently produced by gonorrhoea, and in some cases 
it is accompanied by definite salpingitis and perimetritis. 

Clinically the ovaries are found to be swollen, very tender, and 
often prolapsed ; such ovaries have frequently been removed by sur- 
geons. They present a swollen, congested appearance in the earlier 
stages ; in advanced cases they are extremely swollen, smooth, shiny, 
and almost translucent, the folds and cicatrices being sometimes quite 
obliterated. On section this appearance is seen to be due to oedema 
and probably consequent anaemia of the whole organ. This condition 
in various degrees of severity is one of those most frequently found in 
cases of so-called chronic oophoritis. It is often called oedema of the 
ovary, but better, by Olshausen and others, '' oophoritis serosa." 

In very many cases it is not possible, indeed it may be hardly nec- 
essary, to attempt to distinguish cases of parenchymatous from those 
of interstitial oophoritis. In the acute septic forms the follicles, stroma, 
and vessels are alike affected ; but in the chronic forms there are un- 
doubtedly different degrees of affection of the stroma and follicles. In 
the cases of simple oedema, or phlegmon, it is the stroma that shows 
the most marked changes ; while in chronic interstitial oophoritis, a 
condition which passes by insensible gradations into the various forms 
of fibroma ovarii, both structures are affected, though to a varying degree, 
in different cases. In some the ovary is enlarged, by a marked increase 
in bulk of the stroma, to three or four times its natural size ; in others 
the distended follicles are visible over the whole surface : it will be 
noted that there is no tendency to proliferation of these little cysts. 

All authorities, however, following Olshausen, describe these states 
as constituting definite varieties ; and many attempt a more minute 
classification: but to give distinctive names to every little variation, 
such as is produced by a slight additional extravasation of blood, seems 
more likely to confuse than to advance pathology. And classification 
is further complicated when authors describe as oophoritis cases in which 
the only evidence of such a condition is the presence of one impor- 
tant clinical symptom, the so-called " ovarian pain," or, as it should be 
described, pain referred to the region of the ovary. 

The name " cirrhosis " is applied to various conditions of the ovary, 
about which, in the absence of precise knowledge, there is no general 
agreement. Some apply this name to conditions almost physiological ; 
for instance, to ovaries shrunken and shrivelled by an atrophy, some- 
times perhaps prematurely senile ; others to conditions of the ovary, the 
only abnormality of which is an unusual degree of cicatricial fissuring of 
the surface, — the result in some cases, undoubtedly, of an early develop- 
mental variation, but apparently much more often the result of active 
ovulation ; while others again, with greater propriety, restrict the term 



DISEASES OF THE OVARY 865 

to the minor degrees of fibrosis with more or less dilatation of the 
Graafian follicles. 

Tubercular oophoritis should be considered not only in relation to 
tubercle of the other genital organs, but in relation to tuberculosis in 
general ; for, as I have shown in a communication to the Pathological 
Society of London (10), the ovary is one of the least common seats of 
tubercle, and when tuberculous, it is almost invariably in association 
with tubercle elsewhere; as for instance in the lungs, lymph glands, 
meninges of the brain, peritoneum, oviducts, and uterus. 

Tubercle is found to affect the ovary in two distinct forms : {a) 
miliary tubercle of the surface, usually, but not invariably, associated 
with tubercle of the peritoneum and leading to tubercular perioophoritis ; 
(5) miliary tubercle in the substance of the ovary, which, undergoing 
caseation, usually suppurates, and eventually leads to abscess. 

In the first class of cases the ovary may be of normal size, or may be 
the seat of cystic or other disease. There are no special symptoms, and 
the disease is only recognised on inspection of the ovary during opera- 
tion or after death. 

In the second variety the later stages of abscess are now well known ; 
the diagnosis of the tubercular origin of the disease is, however, a mat- 
ter of surmise until the ovary is itself examined after removal. Its size 
and physical characters naturally depend, not only on the extent of the 
tuberculous disease, but on the degree of suppuration. In this form of 
disease caseous masses will often be found in the abscess cavities, and 
miliary or caseating tubercles in other parts of the organ. The earlier 
stages of the second variety are not rarely met with, and the gross physi- 
cal characters need further investigation ; very few specimens have been 
fully described (4). 

The ovary is found to be enlarged, even perhaps to the size of a 
small apple, without suppuration ; though it is not by any means cer- 
tain whether this enlargement be due solely to the tubercular affection. 
Even if there be no caseation, and the bacilli, as usual in this form, very 
few and hard to find, the microscope, by revealing the histological char- 
acters of tubercle, will place the diagnosis beyond doubt. 

The variety described by Whitridge Williams (37), in his valuable 
paper under the name of "Unsuspected Genital Tuberculosis," does 
not seem to deserve to be raised into a special class. We may reason- 
ably expect that as our knowledge of this affection increases the cases 
included in this particular variety will become rarer. 

Hegar, Olshausen, and Whitridge Williams discuss the possible mode 
by which tubercular infection of the female genital organs can take place, 
but there seems no reason to suppose that, with the possible exception of 
infection by semen, the manner of infection of these organs differs from 
that of other parts. The age of the youngest patient recorded in the 
author's paper was five years, the oldest fifty-live ; five were under four- 
teen years, eight were between fourteen and twenty-five, three between 
twenty-five and forty-five, and one was fifty-five. 

3b: 



866 SYSTEM OF GYNECOLOGY 

The ovary ranks third in the order of frequency with which the 
female organs are affected with tubercle ; the oviducts and mucous mem- 
brane of the body of the uterus being first and second respectively. 

The question of oophorectomy in a case in which the disease of one 
ovary is suspected to be tubercular in origin, is one of comparatively 
easy solution; as in such cases the disease will lead in the majority of 
instances to suppuration, and the treatment will be determined on general 
surgical principles. And if there is a strong probability of the presence 
of tubercular disease in the ovary, and a marked absence of evidence of 
it from other organs, there can be little doubt that the most conservative 
treatment is the removal of the affected parts by a complete operation. 
The oviducts will almost invariably have to be removed at the same time. 

Tlie symptoms of oophoritis are by no means easily distinguishable 
from those due to inflammation of other pelvic viscera, which, indeed, 
is usually present at the same time. In cases of acute septic poisoning, 
with the most active destruction of the ovary, we know of no symptoms 
significant of the ovarian lesion ; the disease is septicaemia, and we do 
not attempt to analyse the symptoms or to recognise the manifestations 
of the disease in an organ so unimportant to life. 

It is in the less severe inflammations that we are able to recognise 
symptoms with distinguishing characters, and in some of them by 
physical examination to diagnose the lesser forms of oophoritis. All 
forms of oophoritis are so intimately associated with inflammation of 
the oviducts and the surrounding peritoneum, that in the present state 
of our knowledge I can only describe the general symptoms. 

Pain is the one constant symptom of all varieties of pelvic inflamma- 
tion, and the site to which it is referred by the patient bears no constant 
relation to the organ affected. The whole region below the navel and 
above the pelvic brim, from the pubes to the iliac spines, back to the 
loins and sacrum, and down the thighs to the knees, is or may be the 
seat of pain in various circumstances ; but we have no trustworthy means 
by which we can distinguish one-sided pains due to affections of the tube, 
ovary, peritoneum, broad ligament, or the body of the uterus or the cervix. 

Those who have read Dr. Head's valuable work on localisation of 
pain due to visceral disease (11), may be disappointed that greater practi- 
cal results have not as yet followed in this and in some other regions of 
the body from his investigations, which are of the highest value, and which 
must in time lead to very important results. The reasons in this case are 
obvious ; the four areas localised by him, namely, 10th, 11th, and 12th 
dorsal, and 1st lumbar, are common in different degrees to the ovary, 
tube, and body of the uterus ; and further investigation is necessary to 
enable us to distinguish disease confined to one of these organs : indeed, 
the common diseases causing pain most frequently affect all these parts. 

The pain is aggravated, as are all pains due to inflammation, by any 
increase of pressure on or within the ovary. The most important cause 
of increased tension within is the premenstrual and menstrual vascular 
congestion, which will set up severe pain at this time. The pain is easily 



DISEASES OF THE OVARY 867 

distinguished from that called true dysmenorrhoea, by the fact that it is 
the aggravation of a pain which continues between the periods ; while 
true dysmenorrhoea is a purely menstrual pain. There are, apparently, 
exceptions to the rule of menstrual increase of pain, for we meet some- 
times with patients who say that the only time they are free from pain 
is during the menstrual flow. 

The pain that persists after coitus may also be due in some cases to 
congestive tension. 

The most constant source of pain from pressure is the general intra- 
abdominal pressure of the various viscera on each other, increased by all 
straining efforts even of a comparatively slight kind. Such pain is re- 
lieved gradually by the horizontal position ; some patients spontaneously 
lie on the back, others on the chest or side. 

Pain is also caused by direct pressure on the organs through the 
abdominal walls, the vagina, or rectum ; as for instance during a medical 
examination, or coitus, or the passage of large faecal masses. 

Of the other great symptoms of pelvic disorder, haemorrhages, men- 
strual or intermenstrual, amenorrhoea, and leucorrhoea, none is known 
to be characteristic of oophoritis. The presence or absence of any one 
of them probably depends largely on the extent of the inflammation of 
the uterus itself, and on the general state of the patient's health. 

Eeference must not be omitted to the wide distribution of neurotic 
symptoms frequently met with in women suffering from various pelvic 
ailments, amongst them ovarian. To discuss this subject adequately 
would require a space beyond that allotted to me, but it may safely be 
said (a) that the local pelvic lesion is most frequently a minor one ; ih) 
that different authors attribute these symptoms to lesions of various 
organs, the commonest lesions being oophoritis, displacements of the 
uterus, and fissures of the cervix; (c) that the symptoms are not gener- 
ally met with in women of robust minds, who suffer from the same 
very common local lesions ; {d) that the nerve symptoms have a great 
tendency to persist after the cure of the local lesion ; (e) and that the 
greatest benefit is obtained by attention to the principles of general 
treatment, that is, by a treatment tending to restore and increase the 
vigour of the mind in a more vigorous body — a restoration, however, by 
no means always practicable. Such cases form a great source of gain to 
all kinds of quack practitioners ; and while some of them are cases of 
great and permanent success and satisfaction to the rational and honoura- 
ble practitioner, many are a continual source of disappointment to all 
whose misfortune it is to be their relatives or medical advisers. 

Diagnosis of oophoritis can be made in some cases with practical cer- 
tainty, when the finger in the rectum, or less frequently in the vagina, 
recognises a tender body of the shape of the healthy organ, but some- 
what larger, lying to one side of or behind the uterus and broad ligament. 

Fixation by adhesions interferes with this ready recognition, and 
unless special means be adopted to make the examination under the 
most favourable circumstances, there will constantly be doubt as to how 



868 SYSTEM OF GYNALCOLOGY 

much of the swelling is ovary, how much tube, and how much adhesions 
and surrounding effusion. 

The most favourable conditions for examination of a difficult case are 
an absence of obesity, the influence of an anijesthetic, the lithotomy posi- 
tion, the evacuation of the rectum and bladder, and the drawing down 
of the uterus by a suitable instrument. Even with these advantages it 
is not surprising that we are foiled at times in our search for precise 
knowledge ; while in some cases, even after removal of the organs, there 
is great doubt how much is ovary and how much tube. And when we 
do succeed, our success is more a source of satisfaction to our pride than 
a benefit to our patient, whose treatment, whether by operation or by a 
prolonged course of medical means, is not materially affected by the 
seat of the disease, whether it be in ovary or tube; the essential thing 
is the diagnosis of the presence of inflammation, its degree, its duration, 
and its effects. 

Treatment. — The general principles which govern the treatment of 
inflamed ovaries are common to all cases of pelvic inflammation; and 
the most valuable, namely, rest in bed, may easily be carried too far, 
especially in the slighter cases ; great care is also needed in watching 
the patient to observe the effects of this treatment on the general 
health, as well as on the local condition ; in order that the physician 
may be enabled to put a proper term to it. And the same close attention 
must be paid to the effects of drugs for the relief of pain. Acute pain 
must be relieved : to this end hot applications to the hypogastric region 
are effectual, and hot vaginal injections also, though to a less extent; 
more direct relief will, in some cases, have to be afforded by such drugs 
as opium. In the protracted cases the application of heat will soon 
lose its good effects; anodynes will not only fail likewise, but will 
become a positive source of danger to the patient : if the suffering is 
genuine and severe, and not out of all proportion to the ascertained 
lesions, removal of the inflamed organ by operation will have to be con- 
sidered, and probably adopted. But in cases where the lesions are small 
and the nerve symptoms great, the treatment should be radically differ- 
ent ; we should endeavour in every way to improve the general health, 
and neglect the local disorder as far as possible. 

HEMATOMA OF THE OvARY. — Extravasatiou of blood into the ovary is 
not rare, but our knowledge of the condition is certainly not very precise. 

It is easily recognisable in three forms : haemorrhage into the stroma ; 
into Graafian follicles ; and into cysts, such as cystic follicles, cysts of 
the corpora lutea, and large proliferating cysts. Hsemorrhage into cysts 
from strangulation of the pedicle, or from rupture of the vessels in the 
very vascular papillary or glandular masses in their walls, has already 
been described, page 850. 

Cysts of the corpus luteum are small and commonly filled with blood, 
the result probably of degeneration of the walls and consequent rupture 
of some vessels. 



DISEASES OF THE OVARY 869 

Minute haemorrhage into the stroma or follicles is also not very rare, 
and appears to have some connection with conditions where there is con- 
siderable and persistent uterine haemorrhage. 

Such haemorrhages into the stroma occur also in acute septic oopho- 
ritis, and during menstruation, apparently normal, into the follicles ; 
Winckel found them in cases of heart disease, typhus fever, phosphorus 
poisoning, and in three cases of extensive burns. 

Sometimes the haemorrhage into the stroma appears to be secondary, 
the result of a ruptured follicle distended with blood. Haemorrhage into 
the ovary, apart from haemorrhage into cysts, is of importance because 
of its effects in increasing the size and weight of the ovaries, and thus 
becoming the cause of pain and prolapse. It is probable that in slight 
degrees it may be a more frequent cause of painful and tender ovaries 
than is generally supposed. 

We have no means of diagnosing this condition; we recognise it 
merely as a pathological phenomenon. 

Prolapse of the Ovary. — The position of the ovaries in a healthy 
woman, lying as they do loosely attached to the superior surfaces of 
the broad ligam.ents (these being more nearly horizontal than vertical in 
the erect position) and to the sides of the uterus, admits readily of their 
descent on the utero-sacral folds, or farther into Douglas' pouch, if the 
normal conditions of their support are disturbed. The abnormal condi- 
tions producing this prolapse are an increase in weight of the ovaries, and 
prolapse, retroversion, or retroflexion of the uterus and broad ligaments. 

The actual prolaj^se may be sudden, the result of a strain ; more often 
it takes place gradually. 

Prolapse of the ovaries is, therefore, only one phenomenon complicat- 
ing various disorders of the pelvic organs; but it deserves special attention 
from the frequency of its occurrence, and from the important symptoms 
to which it may give rise : for it not nnfrequently happens that the symp- 
toms due to the prolapse are the only important symptoms present. 

Prolapsed ovaries may become fixed in their abnormal position by 
adhesions ; a serious complication, as it renders relief almost impossible 
except by means of operation. 

The conditions of the ovary which cause its enlargement are described 
elsewhere: these are simple oedema, inflammation, tubercle, haematoma, 
and incipient tumour formation. Displacements of the uterus are also 
dealt with elsewhere in this System. 

I have here only to describe the symptoms, diagnosis, and treatment 
of the prolapse. 

Symptoms. — Prolapse of an ovary is a displacement of a sensitive 
organ from a position of free mobility and of security from violent 
pressure (namely, between the elastic bowels and broad ligaments) to a 
position in which its mobility is very much restricted (especially if both 
ovaries are prolapsed into Douglas' pouch), and where it is very liable 
to be squeezed by the surrounding parts as the result of general intra- 



870 SYSTEM OF GYNECOLOGY 

abdominal pressure, varying with, muscular exertion and with the 
distension of bowels and bladder. These changes cause more or less 
constant aching, and the pain is increased as the menstrual conges- 
tion recars. Furthermore, the organs are liable to special pressure 
during coitus, and during the passage of large or hard fsecal masses 
through the rectum — both of which disturbances cause sudden and 
severe paroxysms of pain. 

A prolapsed ovary is usually swollen, and is more sensitive to press- 
ure than in its natural position 5 but it is not easy to say whether these 
changes are due to the prolapse or not. The conditions under which 
prolapse occurs are such as would usually cause swelling, and conse- 
quently increased sensitiveness of the organs. 

Diagnosis. — This is comparatively easy in the case of simple pro- 
lapsed, non-adherent ovaries ; a movable, sensitive, often very tender 
swelling of the shape of the healthy ovary, but usually of a somewhat 
larger size, is found lying behind the uterus and (if completely pro- 
lapsed, behind the upper inch of the vagina) in front of the rectum. 

When there are adhesions it is often not at all easy to distinguish 
the ovary from the prolapsed distended extremity of the oviduct. 

The treatment of prolapsed ovaries is always a very troublesome 
matter ; in itself it is a minor disease, but unless relieved, it may be a 
source of continual and great suffering to the patient until the climac- 
teric is well passed. 

If the prolapsed ovary be movable and not greatly enlarged, and 
particularly if the uterus is retroverted, retrofiexed, or prolapsed, relief 
can be given by carefully replacing the uterus, and supporting it and 
the broad ligaments, and, therefore, to a certain extent the ovaries, by 
a suitable pessary of the " Hodge " type; or, if that cannot be borne, by 
an india-rubber ring. The patient in such cases should never be kept 
lying on her back. So long as rest is necessary she should lie in such 
a way that the tendency to prolapse of the ovaries is the least, and this 
will be on the chest or in the semiprone position. This method, com- 
bined with attention to the general health, is usually successful. 

When the prolapsed ovary is adherent, and proper treatment fails 
within a reasonable time to get rid of the adhesions, and allow the ovary 
to return to its natural position, great relief can be given by an opera- 
tion through, the vagina or abdominal wall, having as its object the 
release of the fixed ovary from its prolapsed position, saving it, if pos- 
sible, and, if necessary, fixing it higher up where the pressure effects 
are far less likely to be injurious. 

The operation through the vagina — anterior colpotomy — is destined, 
perhaps, to take the place of the abdominal operation in the majority of 
cases, when further experience has enabled us to select the proper cases 
with certainty ; the operation is one of less immediate risk than abdomi- 
nal section, and it is free from the risk of the subsequent formation of 
a ventral hernia. 

We know of no drugs which have any direct effect on the structure or 



DISEASES OF THE OVARY 871 

functions of the ovary ; its minor diseases are best treated by general 
means, such.. as fresh air, exercise, proper food, daily evacuation of the 
bowels, and tonics ; with avoidance of injurious pursuits and occupa- 
tions. Ovarian pain, in the absence of severe lesions, will be most 
readily and permanently relieved by such measures. 

Hernia of the Ovary. — This is a rare form of displacement of the 
ovary, but the condition is one of considerable practical importance. It 
may be congenital or acquired ; when congenital it is associated with 
persistence of the canal of Xuck, into which the ovary descends ; when 
acquired it is usually inguinal in position : cases are recorded, however, 
in which the ovary has passed out of the pelvis through the crural canal 
(femoral hernia), the great sacro-sciatic notch (gluteal hernia), the 
umbilicus (umbilical hernia), or the linea alba (ventral hernia). The 
condition may be single or double. 

The greater number of cases occur in early youth, but not all of these 
are congenital. Mr. Bland Sutton rightly emphasises the importance of 
extreme caution in diagnosing this condition in little girls. In the 
well-known case recorded in the Obstetrical Society's Transactions by 
Chambers, the supposed ovaries turned out on microscopic examination to 
be testes ; and it is well established that in some hermaphrodites a well- 
developed uterus and external genitals may coexist with testes [vide art. on 
" Malformations"]. This fact illustrates the necessity of a microscopic 
examination of the bodies removed in all cases of supposed ovarian hernia 
in childhood. At this period the condition seldom gives rise to trouble, 
but occasionally the ovary becomes strangulated and has to be removed. 

Symptoms. — Some cases remain undiscovered until puberty, when the 
ovary forms a firm, almond-shaped, generally movable body in the groin 
or the labium majus, and is liable to be mistaken for a lymphatic gland or 
a labial tumour. At the menstrual periods the body is stated to become 
enlarged, painful, and tender. Sometimes it gives rise to continual pain, 
and the patient thereby becomes a chronic invalid. The condition is no 
hindrance to conception, and during pregnancy the ovary may increase 
greatly in size and become very painful ; this appears to result when the 
displaced ovary is the seat of the corpus luteum of pregnancy. In such 
cases abortion is apt to occur. Occasionally a herniated ovary becomes 
drawn up into the abdomen during pregnancy, by the expansion and rise 
of the fundus ; but it reappears after confinement, unless a radical cure 
be, as it should be, effected by operation. 

The displaced ovary is sometimes accompanied by the Fallopian tube, 
and more rarely by the uterus itself, or one horn of a double uterus. 
Sometimes it appears to be drawn into the sac by adhesion to a knuckle 
of bowel or piece of omentum. Frequently the ovary becomes cystic, or 
otherwise diseased ; and a case of a gluteal cyst is mentioned by Boinet 
which was found on removal to be ovarian in origin. 

Tlie diagnosis must in all cases be tentative until verified by 
microscopic examination. When the hernia is irreducible and gives 



872 SYSTEM OF GYNECOLOGY 

rise to considerable trouble, there can be no doubt of the propriety of 
surgical interference. 

W. S. A. Griffith. 

REFERENCES 

1. Amann. "Ueber Ovarialsarkome," ^rc/iiw //^r G?/n. 1894, p. 484. — 2. Auten- 
REiCH. Archiv fur Physiol. Halle, vol. vii. p. 261. — 3. Boinet. Maladies des 
ovaires, p. 73. — 4. Chambers. Trans. Obst. Soe. Lond. vol. xxi, 269.-5. Doran. 
Tumours of the Ovary, 1884. — 6. Edmunds. Trans. Path. Soc. Lond. vol. xl. p. 210. 

— 7. FiscHEL. Archiv fur Gyn. Bd. xv. p. 198. — 8. Flaischler. " Zur Lehi-e 
der Entwickelung der papillare Cysto." Zeit. fUr Geb. und Gyn. Bd. vi. 231. — 9. 
Freund. A7^ch. far Gyn. June 4, 1892. — 10. Griffith. Trans. Path. Soc. Lond. 
vol. xl. p. 212; Trans. Obst. ,'Soc. Lond. 1891, p. 140. — 11. Head. Brain, vol. xvi. 

1893. — 12. Hegar. Die Entstehung u. der Genitaltuberkulose des Weibes. Stuttgart, 
1886. — 13. Jone-1, Dixon. JSf. Y. Med. Journ. May 1890. — 14. Klbbs. " Beitrag zur 
Kenntniss der Ovariotomie und der Ovarialgeschwiilste," Virchoiv's Archiv, Bd. xlix. 
p. 298. — 15. Klob. Handhuch der pathologlscher Anatomic . — 16. Kolaezek. Virchow's 
Archiv, Bd. Ixxv. p. 399.-17. Landerer. Zeit. f. Geb. und Gyn. Bd. xxxi. 1895. 
— 18. Leopold. "Die soliden Eierstocksgeschwiilste," Archiv filr Gyn. Bd. vi. p. 
189. — 19. Marchand. Beitrdge zur Kenntniss der Ovarialtumoren, 1879. — 20. 
Olshausen. Die Krankheiten der Ova7^ien, 1SS6. — 21. Pfannenstiel. Zeit. f. Geb. 
und Gyn. Bd. xxviii. p. 349; Archiv f'dr Gyn. Bd. xl. p. 363. — 22. Rindfleisch. 
Handbuch der pathologischen Anatomic. — 23. Rokitansky. " Ueber die Cysto.' 
Denkschrift der Akad. a Wissen. zu Wien. 1849. — 24. Rosthom, von. Archiv f. Gyn. 
Bd. xli. p. 318. — 25. Schultze. Zeitschrift der Gesell. far Geb. und Gyn. Berlin, 

1894, p. 811.— 26. Shattock. Trans. Path. Soc. Lond. 1889, p. 208.— 27. Simpson. 
Obstet. Trans. Edinb. 1893-4, p. 162. — 28. Sinety, de, and Malassby. Compt. rend, de 
la Soc. de Biol, de Paris, 1876. — 29. Spiegelberg. Monats. f'dr Geburtskunde, Bd. 
XXX. p. 380.-30. Steffeck. Zeit. far Geb. und Gyn. 1894, p. 147. — 31. Sutton. 
Diseases of Ovaries and Fallopian Tubes, 1896. — 32. Thornton. Trans. Obst. Soc. 
Lond. 1882, p. 80. — 33. Velits, von. Virchow's Archiv, Bd. evii. p. 805. — 34. ViR- 
CHOW. " Ueber chron. Affect, des Uterus und der Eierstocke," Wiener med. Woch. 
1856. — 35. Waldeyer. Elerstock und Ei. 1870. — 36. Wertheim. Arch, fur Gyn. 
Bd. xlii. — 37. Williams, Whitridge. Johns Hopkins Hospital Reports, vol. iii. 1893. 

— 38. WiNCKEL. Pathologie der weiblichen Sexualorganes, 18S1. Leipzig. 

W. S. A. G. 



OVARIOTOMY 



Ovariotomy is the term applied to the operation of removal of 
tumours of the ovary. It has also, and conveniently, been made to 
include operations for removal of growths in the paroophoron, the 
parovarium, and the broad ligaments ; this practice will be followed 
here. The general description of the operation will be given for the 
most common and best known variety of ovarian tumour, the glandular 
cystoma ; variations in the proceeding will be described for solid 
growths ; for dermoid tumours ; and for growths, simple and papilloma- 
tous, which open up the layers of the broad ligaments. 

Ovariotomy holds the proudest of positions amongst major surgical 
operations. It cures a certainly fatal disease without leaving deformity 
and without chance of recurrence ; and this with a risk to life which is 



OVARIOTOMY 873 



less than in any other major operation. It is a supreme test of skill in 
the surgical art. Imperfect art or science, bad surroundings or nursing, 
will as certainly be followed by disasters, as the opposite will be followed 
by success. Thanks to those w^ho have gone before us, we have inherited 
a code of rules for the performance of ovariotomy which are probably 
more complete than for any other operation ; the man who knows these, 
and who has helped to apply Miem, wall have success in his w^ork. 
Nothing can replace personal knowledge and experience. It is not 
enough to know everything that has been written, nor even to have 
assisted at many operations ; the best operator must have both advan- 
tages. The very success of the operation has been its curse. The man 
of the old regime who considers that the mortality of a given operation 
is measured by the ability of the man who has passed his examinations 
and nothing more, will soon find his mistake here. The highest success 
in ovariotomy follows the highest training in art, and the most thorough 
education in science. 

It has been one of the pleasing features of the history of the 
operation, that its introduction w^as due to the genius of men who sought 
rather to save lives of patients than to increase their reputation or even 
to advance surgery. The scientific disquisitions of men like Willius, 
Delaporte, JMorand, Hunter, Chambon, Bell, and others had their 
influence ; it remained for the keenly anxious practitioner seeking only 
the salvation of his patient to put them into practice. Ephraim 
M/Dowell, settled in the backwoods of America, w^as in 1809 the first 
of these, thanks to his Edinburgh teaching ; Jeaffreson and King, both 
village practitioners in England, followed. Clay of Manchester took up 
the thread of success ; then, in the hands of Wells in London, Keith 
in Edinburgh, and Tait in Birmingham, it was successfully established in 
the large towns as a great life-saving operation. Increase of success has 
followed the knowledge which these masters have bequeathed in tech- 
nique, and Lister has introduced in science. At the present day it may 
be truly said that ovariotomy has scarcely any legitimate mortality. 
The cases that die are the neglected ones — those wdiich have not been 
diagnosed till far advanced; those in wdiich accidental complications 
have been permitted ; and those w^hich have been repeatedly tapped. 

The actual death-rate of all ovariotomy operations is not easily got 
at; probably it is still over ten per cent. In the hands of surgeons of 
the greatest skill and experience it is about' five per cent. Successful 
series of a hundred cases and over have been secured by several surgeons 
— by myself amongst the number. In the last fifteen years, at least 
half a dozen surgeons in Great Britain, each with cases reckoned by 
hundreds, can speak of a general mortality in ovariotomy scarcely 
exceeding four per cent. 

Preparatory Measures. — Before the performance of ovariotomy atten- 
tion is given to the perfecting of the operative environment, and to the 
preparation of the patient for operation. 



874 SYSTEM OF GYNAECOLOGY 

Measures, special to ovariotomy in respect to operating room and 
furniture, the arrangement of assistants, the provision of instruments, 
and so forth, are to be discussed here. 

Operating Room. — For ovariotomy no special operating room is 
essential. It has been abundantly proved that the operation may be 
performed with as great success in the general operating room of a large 
hospital, or in a bedroom of a private dwelling, as in special rooms elabo- 
rately fitted for the purpose. If the operating theatre is kept as it should 
be for operations in general, it is suitable for the performance of ovari- 
otomy. A specially prepared theatre is a luxury rather than a necessity 
— a saving of trouble in preparing for and doing of the operation rather 
than an addition to its safety. Still the technique is easier, and therefore 
more perfect in convenient circumstances ; and every surgeon would desire 
to perform ovariotomy in a room specially prepared for the purpose, with 
all the accessories that the science and art of antiseptics have introduced, 
and all the aids which experience in the operation has suggested. 

In private the operation is usually done in the room which the 
patient is to occupy during convalescence. A large sunny room which 
can be easily ventilated should be selected. A bedroom in the clean and 
wholesome condition usually found in houses of the upper and middle 
classes in these islands requires little to be done to it. If it be deemed 
advisable to remove carpets or curtains, this should be done at least 
two clear days before operation, so that the germ-laden dust may have 
time to settle. For ventilation a fire in an open grate should be kept 
burning, even in warm weather. A narrow bedstead with spring and 
horse-hair mattress should be used. After the first few days the use of 
two beds, one for the day and another for the night, may add to the 
patient's comfort. A large folding screen which will shield the patient 
from glare without darkening the room may be useful. 

Operating Table. — Many operating tables especially suitable for 
ovariotomy have been devised. A simple deal board on trestles does per- 
fectly well. For private work a portable table such as that of Mr. Bowre- 
man Jessett is convenient. For hospital work a more elaborate table is 
desirable. I have designed a table made of plated steel-tubing and glass, 
which can at once be raised to any height, and made suitable for the 
Trendelenburg, or any other posture. A reservoir, hung under the table 
well away from the surgeon's feet and legs, collects ovarian or other 
fluids. A shoot from the" side of the table conducts the fluids into this 
receptacle from the mackintosh overlying the patient. 

The patient's limbs should be confined during operation, and provi- 
sion should be made for this. In the operating table described this is 
managed by a broad strap of webbing passing over the knees, and by 
wristlets which hold the patient's arms under the table. But a piece of 
strong webbing tied over the knees and under the table for the patient's 
legs, and a strong bandage fixed round her wrists under the table, do 
perfectly well. 

The table is covered either with a special sterilised mattress or a 



OVARIOTOMY 875 



folded blanket. For certain cases it is necessary to adopt measures for 
the application of artificial heat, and some device for this purpose should 
be provided with every operating table. Large copper or aluminium 
reservoirs filled with hot water, and placed under the patient or under 
the table, are sometimes used ; such vessels, made to fit the table, can 
easily be applied under the glass of the table described. If long tubing 
is attached to entrance and exit taps, the water can be replaced by 
fresh hot water during the operation, without disturbing the operator or 
assistants. Hot-water bottles of rubber laid around the patient's body, 
and between and by the sides of her thighs, serve the purpose very well. 
For the majority of casesnospecialapplication of artificialheatisnecessary. 

Coverings of Patient. — The best clothing for the patient during 
operation is a single combination suit, completely enveloping limbs and 
body, and open down the front of the abdomen. Such suits made of 
several layers of fine flannel, or of fine cotton quilted with cotton wool, 
may be sterilised completely without injuring their fabric. If such a 
suit be not available, thick woollen drawers and stockings, and a thick 
woollen jacket, are quite suitable. If there be any special need for it, 
additional security against loss of body warmth is got by packing cotton 
wool under the drawers and jacket, or rolling it round the limbs, and 
securing it with a bandage. For ordinary hospital work, two thick 
blankets sewed together and cut at the sides like a many -tailed bandage 
may be used as a wrap for the patient during operation. To expose the 
seat of operation two of the fiaps are folded back, one on each side ; the 
rest of the body remaining covered. 

Over all is laid a large sheet of mackintosh cloth, in which an oval hole 
has been cut large enough freely to expose the field of operation. An 
opening four inches broad and eight inches long is large enough for 
most ovariotomies. Around this opening on the cutaneous aspect of the 
cloth is spread some adhesive material, such as emplastrum adhesivum ; 
this, heated before operation, serves to glue the mackintosh to the parietes, 
and so prevent soiling of clothes, and secures isolation of the part to be 
operated upon. The mackintosh also prevents loss of bodily heat by 
radiation, and keeps away from the wound particles of wool, cotton, or 
other dust given off by the clothing. 

Prepm-atioji of Patient. — The general preparation of the patient in- 
cludes free opening of the bowels ; it is better to do this by gentle purga- 
tion for two or three days before operation than by a single sharp purge 
the night before. During the twenty-four hours preceding operation all 
food should be either liquid, or of a nature to leave little residue in the 
intestines. The last meal will be regulated by the orders of the anaes- 
thetist. Many surgeons give the patient morphia before operation ; a 
few speak highly of the value of strychnia given hypodermically as 
a means of keeping the bowels contracted during and after operation. 
A thorough cleansing of the whole body in a bath with soap shonld 
precede operation. 

Locally the seat of operation is purified in the manner described 



876 



SYSTEM OF GYNECOLOGY 



under "Antiseptics" (p. 270). The pubic liair is shaved. The risk of 
infection, however, lies rather in the numerous and large hair-follicles in 
this region than in the hair ; it is indeed doubtful if this region is ever 
rendered perfectly sterile. Therefore it is wise at and after the operation 
to use active antiseptics on the skin over the pubes. A good plan is to 
rub powdered boric acid dissolved in carbolic lotion into the skin in 
this region. This plan will certainly keep the skin sweet for a week; 
thereafter the risk is over. 

Arrangements for Operatioyi. — The placing of the table, surgeon, and 
assistants is shown in the accompanying diagram. The patient's feet are 
towards the window or chief light. The surgeon stands on the patient's 
right ; his assistant — only one operating assistant is necessary — opposite 




Q 



^^ANS FOR 



^ 



jCHLORCFORMISTJ 

















RECEPTACLE FOR FLUID 





jOPERftTOnj 




TABLE WITH 
INSTRUMENTS 
SJ.ICATUBES 



Fig. 212. — Diagram to show placing of table, surgeon, assistants, nurse, and instruments 
in ovariotomy. {After Doran.) 



to him on the patient's left. The nurse stands behind the assistant, takes 
sponges from his hand, cleanses them, and returns them dry as they are 
wanted. The instruments lie on trays covered with sterilised water, or 
in antiseptic solution, close to the surgeon's right hand. The surgeon 
should help himself to instruments — an assistant to hand them imports 
another risk and is quite superfluous. A swinging tray, attached to the 
table on which the instruments are placed, which can be brought close to 
the seat of operation, is a convenience for holding the instruments which 
are in constant use. 

Sponges and Sponge-cloths. — A dozen sponges of undoubted purity 
should be in readiness. These should be assorted as follows : two large 
flat sponges, two medium flat, and eight round of various sizes. The 
sponges should be of the finest Turkey growth. 

Two dozen sponge-cloths kept in warm sterilised or antiseptic solu- 
tion are also at hand. For absorbing fluids and blood, for covering 
extruded bowels, and in numerous other ways, sponge-cloths are invalu- 
able. They are laid on the mackintosh all round and close up to the 



OVARIOTOMY 877 



parietal wound, keeping the operating field aseptic and absorbing any 
fiuids that escape. As soon as a sponge-cloth is soiled the assistant 
quietly replaces it by a fresh one. As a rule, sponge-cloths only are 
used during the making of the parietal wound, and many operations are 
finished without the use of a single sponge. 

Artificial sponges, made of pads of absorbent material in gauze bags, 
are used by some surgeons. They do not absorb so well as natural 
sponges ; and they are no more safe, if due care be observed in prepar- 
ing the natural ones. If gelatinous fluid has to be removed from the 
cavity of the abdomen natural sponges are almost essential. 

Instruments. — The surgical armamentarium may conveniently be as 
follows : — 

One scalpel ; one scissors, dissecting, elbowed ; one scissors for 
sutures and pedicle, flat ; twelve haemostatic pressure-forceps, small ; 
six haemostatic pressure-forceps, medium ; two T-shaped forceps ; four 
cyst-forceps — large — straight ; four cyst-forceps — large — bent ; one 



Fig. 213. — Tail's modification of Wells' catch-forceps. 

forceps for placing pedicle ligature; one cyst-trocar — Tait's large; one 
cyst-trocar — Wells' — Fitch's dome; one suture-needle (several sizes 
of needle) ; one reel-stand with silk ligatures ; six glass drainage tubes 
— assorted. 

With these instruments most ovariotomies may satisfactorily be 
performed. In reserve, however, and sterilised ready for use, should 
be the following : — 

Aspiration apparatus ; intestinal needles ; Lane's intestinal clamps ; 
cautery irons, or thermo-cautery ; a second dozen of pressure-forceps ; 
abdominal retractors ; means of providing artificial light with mirror, 
electric apparatus, or otherwise. 

The instruments are arranged in trays containing warm sterilised 
water or carbolic lotion. They should be arranged in groups, and so 
placed that the surgeon can put his hand in a moment on the instrument 
he wants. An instrument after use is replaced in its tray. The tro- 



878 



SYSTEM OF GYNMCGLOGY 



cars, with tubing attached, are placed in a special large basin. The 
reel-holder, containing at least four sizes of Chinese silk, stands by 
itself; the ligatures are pulled out and cut off by the surgeon himself 
as they are wanted. 

Some of the most important instruments may be briefly described. 
Of forceps, the best and most generally used is that known by Spencer 
Wells' name (Fig. 21 3) . Tait has, I think, improved the model by making 
the blades shorter and more pointed, thus giving more power in grasp, 
and permitting the ligature to slip more easily over the point. In these 
instruments the blades are serrated transversely to their length, and the 

tissues caught in them are thus 
flattened out and wrinkled, while 
o Nb^^^ lateral traction is liable to cause 

"'"* ^,-^^^^ them to slip. 

For some years past I have 
been using forceps of the same 
size and shape, in which the 
serrations are carried round the 
blades parallel to their margins 
instead of across them. The 
tissues are thus sharply compressed along two lines, and an uncom- 
pressed bulb of tissue lies in the centre of the blades which effectually 
prevents slipping, and serves to hold the ligature. 




Fig. 214. — Catch-forceps. (Author's model.) 







Fig. 215. — Blades of author's forceps. 



As hsemostatic agents these forceps are, in my opinion, superior to 
those with serrated flat blades ; they sharply com- 
press, almost divide, any vessel included : rarely 
has any ligature to be applied to a bleeding point 
on which they have been placed. They are made ^m. 216. - Au^hor'^s^pentoneai 
in all sizes and shapes. The smallest size (Fig. 216), 
with one biting edge and a sharp point, is used for picking up the 



OVARIOTOMY 



879 



peritoneum ; of larger size they are useful in seizing the slippery cyst- 
wall, and in holding omentum that has been stripped. The largest 




Fig. 217 —Large pressure-forceps; straight. (Author's model.) 

size is convenient for grasping broad masses of tissue, and is made 
straight, T-shaped, and bent at various angles. These instruments are 




Fig. 219. 

Wells' large forceps, bent (Fig. 218) ; and straight (Fig. 219). 

all made on the Wells' pattern as regards handles and blades ; the only 
variation is in the form of the biting surfaces of the blades. 

The large forceps of Wells, straight and bent (Figs. 219 and 218) ; the 



88o SYSTEM OF GYNAECOLOGY 

same instruments with the blades at right angles (Fig. 220) and T-shaped 
(Thornton) (Fig. 221) are in universal use and are highly appreciated; 




Fig. 220, — "Wells' lar^e pressure-forceps, rectangular blades ; \ size, 

their handles are similarly shaped ; they all have the rack catch, which 
is quickly applied and released, and they are very powerful. A clamp 




FiGi 221. —Thornton's T-shaped pressure-forceps ; | size, 

forceps with screw compression used by Wells (Fig. 222) may occasion- 
ally be found useful. 

For grasping and dragging out the cyst, Kelaton's special forceps 
(Fig. 223) have been much employed and found very valuable. The 
spikes in the blades are supposed to add to their holding power ; I think 
they tend to lacerate the parts. 

Excellent cyst-forceps are those of Sydney Jones (Fig. 224), but as 



OVARIOTOMY 



88i 



cyst-forceps I consider those already described with, double parallel 
serration to be the best. 

On cutting instruments little need be said. I have used the same 




Fig. 222. — TV ells' clamp-forceps ; § size. 



scalpel in several hundreds of operations; it has never been to the 
instrument maker^ but is sharpened by a few strokes on steel or hone 




Fig. 223. — Nekton'' s cyst-forceps ; \ size. 



before every operation. The scissors which I use have the same handles 
as catch-forceps ; their blades are bent a little, rounded, and rather sharp 






Fig. 224. — Sydney Jones' cyst-forceps. 



pointed. They are useful in delicate as well as in coarse work. Sepa- 
rate scissors, curved on the flat, should be used in the division of liga- 
tures and sutures. 

The ligatures used in ovariotomy are most conveniently made of silk ; 
Chinese twist in four assorted sizes, from the smallest to the largest, will 

3l 



882 



SYSTEM OF GYNECOLOGY 



suffice. These ligatures must be absolutely aseptic. For keeping the 
ligatures I can confidently recommend my own holder (Fig. 226). It is 




Fig. 225, — Author's scissors. 



composed of a stand with weighted base made of metal which will not 
rust, and which can be removed and placed in boiling soda solution ; and 
of a vulcanite case with screw cap, which is air-tight. If the stand with 




Tig. 226. — Author's reel holder ; \ size. 



the reels is boiled now and again, and 1-20 carbolic lotion poured into it 
for every operation and decanted afterwards, the silk, thus kept in car- 
bolic vapour and away from the possibility of contamination by air, may 
always be trusted. 

These instruments are in constant use throughout the operation. 
Special instruments required in special parts of the operation are tap- 
ping trocars, pedicle needles or forceps, drainage tubes, and needles for 
placing the sutures in the parietal wound. 



OVARIOTOMY 



883 



Of tapping trocars the best known is Spencer Wells' (Fig. 227), which 
contains an inner blnnt tube in an outer cutting tube, and two spring 
clasps with sharp teeth to hold the cyst wall. A very useful tube in 




Fig. 227. — Wells' large cj'st-trocar ; \ size. 




Fig. '228. —Wells' small cyst-trocar -^itli Fitch's dome ; \ size. 




Fig. 229. — Tait's C3-st-trocar ; \ size. 



smaller size was also designed by Wells, with Fitch's safety dome which 
can be pushed beyond the cutting point (Fig. 228). 

The trocar which I like best is that of Lawson Tait (Fig. 229). It 
does not cut at all ; it pierces and dilates. It is a simple piece of metal 



SYSTEM OF GYNECOLOGY 



tubing, bluntly conical, and bent to a right angle in the shaft. It can 
be had of all sizes ; the largest size is rarely too large. 

To the trocar is attached a piece of thick rubber tubing of the same 
calibre as the trocar. The tubing must have thick walls to prevent the 
chance of its becoming blocked by kinking. 

For carrying the ligature through the pedicle various needles are in 




Fig. 230. — Sydney Jones' pedicle needle. 

use (Figs. 230, 231). Any needle will do if it is curved, handled, and 
blunt. An aneurysm needle does very well. I employ a forceps with 




Fig. 231. — Wells' pedicle needle. 

blades and points like those of Lister's sinus forceps, but bent (Fig. 232). 
The closed instrument is pushed through the pedicle ; the blades are 




Fig. 232. —Author's forceps for placing ligature on pedicle. 

then opened and made to grasp the ligature which is placed during 
withdrawal. 

Of drainage tubes the original ones of Keith (Fig. 233), of the 



Fig. 233. — Keith's glass drainage tube ; § size. 

same diameter throughout, with a collar and with a few perforations 
near the point, are still the best. 



OVARIOTOMY 



885 



For the drainage of large opened up spaces a drainage tube, shaped 
like a test-tube, with perforations nearly all the way up, is sometimes 
of advantage (Fig. 234). The sharp rim of a Keith's tube must not be 



Fig. 23i. — Glass drainage tube ; \ size. 

pressed down on the rectum or other part of bowel for any long time, 
as it may cause perforation. 

A sponge-holder, with blades long enough to reach to the loins, should 
be amongst the instruments in readiness (Fig. 235). 




Fig. 235. — Sponge-holder ; | size. 



In placing the sutures in the parietal wound most surgeons have 
special methods of their own. The instrument shown (Fig. 236) does 




Fig. 236. — Author's suture instrument: i size. 



equally well for silk or for silk-worm gut. The silk, preferably plaited, 
is held on its reel in a cavity in the handle, which is filled with antiseptic 
solution. If silk-worm gut (in my opinion the best suture material) be 
used the reel is discarded, and each suture is passed into the eye of the 
needle after the needle has been carried through both sides of the 
incision : the suture is thus placed on its withdrawal. The needle is on 
Hagedorn's principle, except that the eye is at the point. Hagedorn's 
needles, used with his holder, serve the purpose admirably. Some sur- 
geons use ordinary glover's or similar needles. 



886 SYSTEM OF GYNECOLOGY 

The Operation. — The patient being anaesthetised, and sponge-cloths 
wrung out of warm lotion having been laid around the field of operation 
on the mackintosh, the actual operation is begun by '■ — 

The parietal incision, which is made in the middle line, and lies, as a 
rule, midway between umbilicus and pubes. If the tumour be large the 
incision lies nearer to the pubes than to the umbilicus. It is not advisa- 
ble to go closer to the pubes than two inches, on account of the prox- 
imity of the bladder ; if it be necessary to enlarge the opening the wound 
is extended upwards. The first incision will vary from two to five inches 
in length, according to the thickness of the parietes and the amount of 
solid matter in the tumour. In a few cases it may have to be enlarged 
to six or eight inches. 

The first cut usually divides the skin and fatty tissue down to the 
fibrous aponeurosis. In very stout persons the fatty layer may be several 
inches in thickness, and this may be increased in thickness by oedema. 
In very thin persons, with distended abdomen, the subcutaneous fat may 
be absent. Catch-forceps are placed on bleeding points : these may be 
removed as soon as the cavity is opened ; in a few seconds hsemostasis 
will be complete and permanent, and ligatures will be unnecessary. 

The fibrous aponeurosis is next divided as nearly as possible in the 
linea alba. A glance at the arrangement of the fibres will often, by their 
symmetrical arrangement on the two sides, show the exact middle line ; 
but frequently the linea alba is not hit off, or not divided at all, but one 
or other sheath of the rectus is entered. In persons with powerful 
recti, and not very distended parietes, the linea alba may be no more 
than a thin fibrous septum ; in women with thin or distended parietes 
the linea alba may be broad, and there will then be no difficulty in 
avoiding the recti. But to expose either or both muscles does no harm ; 
indeed, some surgeons say that to expose muscle and bring it into the 
line of union is a distinct advantage, as it helps to prevent ventral hernia. 
There is certainly no advantage in being far from the middle line ; if the 
sheath be opened it should be close to the linea alba. A small cut is 
made with the scalpel through the thick aponeurosis ; a glance will 
show whether it is far from the middle line, and on which side : it is 
then extended upwards and downwards towards the middle. Below 
the falciform edge, where most operations are done, there is no more 
aponeurosis to divide ; above this level the wall of the sheath of the 
rectus remains to be divided. 

The subperitoneal fatty and areolar tissue is now exposed. It is 
naturally very loose and elastic, and it can readily be teased apart so 
as to expose the underlying peritoneum. Occasionally it is very sparse 
in amount; sometimes it is thickened and hardened by inflammation, 
and firmly adherent both to peritoneum and to muscle. The fat is 
pushed to one side and the other, and a minute portion of peritoneum is 
caught up in the fine peritoneal catch-forceps and pulled to the surface. 
A second forceps is placed close to the first, by its side ; the minutest 
grip suffices to give a holding. Between the two pairs of forceps the 



OVARIOTOMY 887 



raised fold is gently sawed through by a knife, air rushes in, the bowels 
fall back, and the opening is enlarged to a size sufficient to admit the 
forefinger. The left forefinger is introduced through the opening, and 
the peritoneum divided on it upwards and downwards to the full extent 
of the outer incision by scissors. Any small vessel which bleeds is at 
once seized in catch-forceps, which are left hanging for a few seconds, 
or till after the cyst is emptied. 

In ovariotomy the incision has rarely to be increased beyond a length 
of four or five inches. This is best done by scissors dividing the whole 
thickness of the wall at each stroke. If the incision has to be carried 
above the umbilicus it should be carried to the left of it ; this is done to 
avoid the round ligament of the liver and the thin tissues, not suitable 
for holding sutures, in the umbilicus itself. 

When the peritoneum is adherent to the underlying tumour its 
separation requires some judgment and experience. It has frequently 
happened that peritoneum has been stripped from parietes in the belief 
that tumour was being stripped from peritoneum. An inflamed and 
thickened peritoneum is usually vascular and somewhat friable. 

Emptying and delivering the Cyst — Separation of Adhesions. — The 
tumour being exposed and found suitable for removal, it is tapped 
at once. It is unnecessary to introduce fingers, still less the hand, un- 
less the diagnosis be doubtful. Adhesions are best left till the cyst is 
emptied. 

A. point for inserting the trocar should be selected in a large and 
thick-walled cyst ; small thin cysts and the sulci between them should 
specially be avoided. Tait's large trocar is, as a rule, the most con- 
venient. If the cyst-wall be thick a slight cut with a scalpel through 
the outer layers facilitates the introduction of the blunt point of the 
trocar. The trocar is plunged in with the left hand, and fluid at once 
flows into the receiver through the rubber tubing. Almost simultaneously 
the cyst-wall below the trocar is grasped in cyst-forceps held in the right 
hand, and is pulled to the surface. Deft manipulation will always avoid 
the escape of fluid into the peritoneal cavity, and will bring the rapidly 
collapsing cyst-wall outside the parietal incision. The parietes are not 
pressed back on the cyst; rather is the cyst pulled outwards and on to 
the parietes. A second pair of forceps, placed on the cyst above the 
trocar, suffices to hold the opening in the cyst outside the wound during 
the emptying, and perhaps to deliver the whole tumour. 

Delivery is prevented by the presence of semi-solid polycystic material 
in the growth, and by adhesions. Secondary cysts may be emptied one 
after the other by pushing the trocar into them. If they are very closely 
set and very numerous, the trocar is now removed, and two fingers of 
the right hand are carried through the opening to break the numerous 
small cysts into the large one ; or the openings in parietes and cysts 
may be enlarged and the whole hand introduced to break up the cysts. 
Meanwhile the assistant, holding the large catch-forceps, keeps the cyst 
opening well outside the parietal opening, and turns it so that any fluid 



SYSTEM OF GYNECOLOGY 



escaping shall run over the mackintosh into the receptacle provided. If 
the fluid be very foul a sponge-cloth or two laid around the parietal open- 
ing will provide additional security against its entering the abdominal 
cavity. When the whole of the semi-solid matter has been broken up the 
hand is removed, and the contents are squeezed out by pressure on the 
parietes : these run over the mackintosh into the vessel under the table. 

The cyst may now be delivered through the parietal opening. This 
is done by traction on the attached forceps, one pair after another being 
placed as the tumour comes out. If the walls are very friable the largest 
forceps, with slight compression, should be employed. The advantages 
of my instruments, which hold very firmly, and neither pierce nor cut, 
are most conspicuous in the handling of cysts with friable walls. 

If delivery is prevented by adhesions these are now dealt with. If 
the cyst has not been completely emptied, and if there is any risk of the 
fluid escaping into the cavity, the opening in the cyst is closed by press- 
ure-forceps suitably placed around the opening. Adhesions, wherever pos- 
sible, are separated within sight ; but many adhesions, such as those to the 
liver, must be separated far from vision by fingers. In the separation of 
fine, soft, or recently formed adhesions, the hand or fingers working their 
way over the cyst-wall easily succeed. Such adhesions bleed very little, 
and the bleeding soon ceases. The use of a sponge is often advisable. 
The adherent organ is sponged away from the cyst- wall ; if there is any 
bleeding the sponge is left on the detached organ, and removed later 
with the blood which it will have absorbed. Firm adhesions must be 
dealt with more deliberately. Sometimes they may be peeled off by the 
fingers, or fingers aided by sponging ; each strip of adhesion is examined 
for bleeding after detachment, and a forceps placed on it. Old, firm, and 
fibrous adhesions are divided and tied on the distal side ; a catch-forceps 
is left on the tumour side, and removed with the tumour. Omental 
adhesions are perhaps the most common ; they can usually be peeled off, 
but nearly always demand forcipressure. Coils of intestine adherent in 
the sulci between cysts require very careful handling. It is better always 
to detach a piece of cyst-wall with the gut than to injure the latter by 
tearing, or by denuding it of its outer coats. 

Forceps holding bleeding points in adhesions are, wherever possible, 
brought outside the parietal opening, and laid on and covered up by 
sponge-cloths. 

Where the adhesions lie deeply large forceps are attached the handles 
of which remain outside ; and sponges in such cases are packed inside the 
abdomen over the rawed surfaces. When the tumour is delivered and 
cut away the forceps are removed one after another ; and the tissues 
caught in their blades are closely examined. In most cases where for- 
ceps have been compressing bleeding vessels hsemostasis will be perfect, 
and the adhesion may be allowed to slip inside. Where there is any 
sign of bleeding or of oozing, a silk ligature is placed before the adhesion 
is returned. In bad cases from a dozen to two dozen forceps may be 
left on, each holding its own bleeding point ; yet when they come to be 



OVARIOTOMY 



removed a few minutes later, not a single ligature may have to be 
applied. 

Treatment of the Pedicle. — The pedicle is now almost universally 
secured by ligature, the stump being dropped into the abdominal cavity. 
The only method which for safety can compete with intrax-)eritoneal 
ligature is that of Thomas Keith by clamp and cautery. As, however, 
this is more troublesome and no more safe than the method by ligature, 
the latter alone will be described. 

The material which is most convenient for ligation is the silk thread 
known as " Chinese twist." Silk can be sterilised easily and satis- 
factorily by boiling. It does not swell, and it holds firmly the grip 
which we make it take. It becomes quietly encapsuled, remaining 
quiescent in its bed, and is slowly absorbed in the course of a few 
months. 

Various thicknesses of silk are used according to the size and the 
vascularity of the pedicle. By compressing the pedicle along the line 
of ligature with strong forceps, the chief necessity for using very thick 
silk — to bear a strong strain in tightening — is done away with. Silk 
of medium thickness will easily check the bleeding if the fibrous tissues 
which surround the vessels and protect them from compression are first 
squeezed by pressure-forceps. The silk should always be strong enough 
to bear the strain of hands of moderate strength, but need not be so 
strong that it cannot be broken. It is better to tie the pedicle in several 
sections with silk of moderate thickness than to tie in one or even two 
masses with very thick silk. In every case, if only to prevent slipping, 
it is wise to use a transfixing ligature. 

To carry the ligature through the pedicle a blunt instrument should 
be used, so as to prevent the possibility of wounding any of the thin- 
walled vessels. The blunt needles of Sydney Jones (Fig. 230), or of 
Spencer Wells (Fig. 231), serve the purpose admirably. An aneurysm 
needle, if it has a long curve, does very well. I use a curved forceps 
with blades like a sinus forceps (Fig. 232) ; this is pushed through the 
pedicle at the points selected : its blades are opened after being passed 
through, and the ligature is caught in them and placed during withdrawal. 
All trouble of threading and unthreading is thus done away with, and a 
series of ligatures can be placed with great rapidity and ease. 

If a simple transfixing ligature, securing the pedicle in two sections, 
be used, no method is superior to that of Lawson 
Tait by the Staffordshire knot (Fig. 237). If 
the forceps be used the ligature is placed with 
great ease. Firstly, the forceps is passed through 
the pedicle ; then the silk is placed below it 
around the whole pedicle; then the two free 
ends are caught between the opened blades and fig. 23T.—Tait'8 Staffordshire 
withdrawn. One end of the ligature is placed 

above the encircling loop, and another below. The two ends are pulled 
tightly by the right hand, while the finger and thumb of the left hand 




890 



SYSTEM OF GYNECOLOGY 




Fig. 288. — Triple interlocking ligature ; 
threads inserted, loops divided. 



compress the line of ligature ; the knot is cast and tied in the ordinary 
way. If a needle be nsed to carry the ligature through, the loop is 

raised over the tumour to the side of 
entrance, and the two free ends, one 
above and one below the loop, are tied 
as described. 

If the pedicle be a large one it may 
conveniently be tied in three or more 
sections. The ligatures should always be 
made to interlock, so that the whole mass 
is kept together, and there is no down- 
ward splitting with possible injury to 
delicate vessels. With the pedicle-forceps 
a series of ligatures may be very rapidly and easily placed in one long 
thread (Figs. 238, 239, 240). Two, three, or four loops are pulled through 
as we desire to place three, four, or five 
ligatures ; the loops are divided, and the 
ligatures then lie ready for tying. The 
middle ligature is tied first ; and before a 
ligature is tied the ligature on each side 
should be looped in it. With a properly 
placed interlocking or chain ligature, the 
largest pedicle may be compressed into 
wonderfully small bulk. Compression by 
large forceps along the line of ligature 
will materially facilitate the tightening. 

While the ligatures are being tied there should be no traction on the 
pedicle by the weight of the tumour, or otherwise. In vascular or fleshy 

pedicles it is often good practice to hold the 
ends of the ligature, and to keep tightening 
it while the assistant cuts the tumour away ; 
the same purpose is served by forcipressure. 
When the ligatures are tied, and the tumour 
is cut away, a final examination of the stump 
and ligatures is made, and if all be secure 
the pedicle may be let slip into the cavity. If there is sponging or 
further manipulation to be carried out, I usually place a medium-sized 
forceps on the tissues in the middle of the stump, and leave it there till 
the end of the operation, when a final glimpse is given to it to make 
certain that all is secure. 

In placing the ligature there is no advantage in getting deeply inside 
the abdomen or close to the uterus. The ligature should be about half 
an inch away from the tumour, and division is made by knife or scissors 
just free of tumour tissue. No doubt tumour tissue has often been left 
behind in the stump, yet it is a significant fact that no case of recurrence 
of ovarian tumour on the side of removal has yet been recorded. 

In cases of torsion of the pedicle I place the ligature at the site of 




Fig. 239. — Triple interlocking ligature : 
threads interlocked ready for tying. 




Fig. 240. — Triple interlocking ligature 
threads tied. 



OVARIOTOMY 891 



greatest twisting, and do not undo the tTvist. The ligature is thus made 
to complete what nature has begun. In cases of large fleshy pedicles a 
flap of peritoneum may be left to cover the raw surface, and so serve to 
minimise the risk of obstruction from intestine getting adherent to it. 
It can easily be fixed over the stump by a continuous suture of fine silk. 

When the pedicle is secured the alternate ovary should be examined. 
If there be any sign of disease it also should be removed. 

Tlie '• Toilet of the Peritoneum.''^ — The wound should not be closed 
until all foreign matter — such as blood, ovarian or ascitic fluid, or pus 
— has been removed from the abdominal cavity. In most cases, after 
delivery of the tumour and before division of the pedicle, a sponge will 
have been placed inside the abdomen under the parietal wound. This 
sponge will have gathered to itself any free fluid that may lie in the 
lower pelvis, and its contents on removal after ligature of the pedicle 
will be some guide to the amount of fluid present. A sponge in a long 
sponge-holder (Fig. 235) is dipped into the pelvis behind the uterus. 
If it return dry, or nearly so, no further sponging is necessary. Then 
the sponge is carried successively into each lumbar hollow over the 
kidney to make certain that no fluids have gravitated thither. 

If the fluid be present in moderate amount it is removed by successive 
introductions of sponges. Each saturated sponge is squeezed dry, cleansed 
in sterilised soda solution, placed in hot carbolic lotion, again squeezed 
dry, and returned to the surgeon, who picks it up in the sponge-holder 
and reintroduces it. Blood in the presence of ascitic fluid clots at once ; 
and Aviping of surfaces, or even a little friction may be necessary to re- 
move it. Glairy, thick ovarian fluid is not readily mopped up ; rotation 
of the sponge helps in its removal. If, by mischance, pus have escaped 
into the cavity, irrigation is, I think, always advisable. 

Irrigation is to be used when there has been much wounding of 
peritoneal surfaces with escape of blood ; or where pus or thick ovarian 
fluid has escaped into the peritoneal cavity. This is done by pouring 
into the cavity some unirritating sterile fluid, and literally Avashing the 
bowels and peritoneum in it. Of all fluids, for this purpose the least 
irritating is, in my experience, a solution of Barff's boroglyceride of the 
strength of half an ounce to the pint of water. Saline solution and 
simply sterilised water may safely be used, but these cause more 
injury to the delicate endothelium than boroglyceride. The fluid 
should be at a temperature of 100° F., or even a few degrees warmer. 
The solution may be poured in out of a jug while the edges of the pariG' 
tal wound are dragged forwards. The fingers then freely move the 
intestines about in the fluid, washing them, disturbing clot and breaking 
it up. By depressing the parietes the fluid is permitted to flow out, ana 
is guided over the mackintosh into the vessel provided for its reception. 
I prefer always to use irrigation, the reservoir being raised from three to 
six feet above the patient, according to the cohesiveness of the materials 
to be removed. A specially devised glass tube with perforated bulbous 
ends is attached to the rubber comins: from the irri.srator: and this, 



892 SYSTEM OF GYNECOLOGY 

throwing out numerous jets of fluid, is carried over all the districts 
which it is desired to cleanse. The wound is pinched round the tube 
until some pints have flowed into the abdomen, and it has begun to be 
distended ; the wound is then made to gape, and the fluid comes out with 
a gush carrying debris with it. This may be done repeatedly till the 
fluid returns quite clear. A little judicious manipulation, accompanied 
with kneading of the parietes, and perhaps turning of the patient on one 
side, will cause most of the fluid to escape. If drainage is to be carried 
out it is not necessary to remove the fluid, in fact it is, I think, better to 
leave it behind, for clotting of blood does not then take place ; if there 
is to be no drainage the fluid must be removed by sponging in the manner 
directed. 

If irrigation is employed there should be no stinting of fluid — 
gallons rather than pints should be the measure. The bowels should be 
freely moved about with the fingers in the cavity during the irrigation, 
so as to ensure disturbance of every lurking particle of foreign matter. 

It is possible to overdo the peritoneal cleansing. Too much spong- 
ing irritates the peritoneum and causes it to secrete fluid, and removal 
of every particle of clot encourages vessels to go on bleeding. Sponging 
may cease when no more than a drachm of fluid can be squeezed from 
the sponge. If the drainage tube is to be employed, as will usually be 
the case after irrigation, sponging is not called for at all. 

Drainage. — It is quite impossible to lay down accurate rules as to the 
employment of the drainage tube in ovariotomy. It is certainly true 
that drainage has done more good than harm ; with moderate care it can 
scarcely do harm : therefore it is a good rule to drain when in doubt. 
If fluids do not come away the tube may be removed in twenty-four 
hours, and no harm is done. If fluids do come away we have the satis- 
faction of seeing the good done. 

If we expect a pouring out of fluid, serous or sanguinolent, more 
rapid than the peritoneum can dispose of we should drain. This would 
occur after extensive traumatism in the separation of adhesions. If we 
expect bleeding from vessels which cannot be secured we should drain, 
and in any case where haemorrhage is feared we should drain. In all 
cases where purulent or septic fluid has escaped into the cavity we should 
drain. Where intestine or bladder or other viscus has been wounded, 
with escape of their contents, we should drain. And in most cases where 
irrigation has been employed it is wise to drain. 

Keith's drainage tubes (Fig. 233) are for most cases the best. The 
tube selected should be long enough to reach the bottom of the pouch of 
Douglas without pressing on the rectum, while the collar rests on the 
skin at the lower end of the wound. Inside the tube should be placed 
a few strands of gauze or thread to act as capillary drains. A circular 
sheet of rubber, in the centre of which a hole has been cut to a^dmit the 
end of the tube, is folded over an absorbent dressing (nothing is better 
for this purpose than a sponge-cloth wrung out of warm carbolic lotion) 
which is removed as often as it is saturated. If there be bleeding, 



OVARIOTOMY 893 



frequent use of a suction apparatus to keep the abdomen perfectly dry 
is advisable. Tait's suction apparatus, or an ordinary glass syringe 
with a piece of rubber tubing long enough to reach to the bottom of 
the glass tube, should be employed for this purpose. If there is no 
clotting the capillary drain will serve to keep the abdomen dry without 
the use of the suction apparatus. 

The gauze drain is very rarely employed after ovariotomy. 

In most cases drainage need not be continued longer than two or 
three days ; a few cases require drainage for a week or even longer. 
If the wound is thoroughly aseptic the opening made by the tube 
closes at once without suppuration. 

Before placing the drainage tube it is a good plan to insert a silk- 
worm gut suture through the parietes at the point where the tube 
passes, and leave this to be tied after the tube is removed. 

Suturing the Parietal Wound. — Some surgeons suture the wound in 
layers, each tissue having its row of buried sutures, interrupted or con- 
tinuous. Most are contented with interrupted sutures, of which each 
includes all the layers in the parietes. Each suture should include skin 
and subcutaneous tissue, take a good hold of the fibrous aponeurosis, 
dip deeply into muscle, and pick up subperitoneal areolar tissue suffi- 
cient to give close peritoneal apposition on the raw surface. It should 
not pierce peritoneum. The sutures should be placed from two to four 
to the inch ; thin and lean parietes require more sutures than thick and 
firm parietes. 

As suture material silk-worm gut is unrivalled. For insertion of the 
sutures a curved needle on the Hagedorn plan is recommended. An 
ordinary Hagedorn needle does very w^ell. With the needle which I 
employ (Fig. 236) the sutures can be placed with accuracy and rapidity. 

Before suturing is begun, a sponge of suitable size is placed in the 
cavity under the parietes to keep bowels out of the w^ay, and to collect 
any blood that may escape from the needle punctures. When all the 
sutures are placed the assistant grasps their ends in his two hands ; 
the- sponge is then removed and, from above downwards, the sutures 
are tied. If drainage is used, an extra suture may be placed where the 
tube passes, but is not tied ; it is tied when the tube is removed. 

A wound which is properly sutured should not be depressed, but 
should rather pout or bulge outwards. By burying the sutures deeply in 
the parietal muscle and fibrous tissues the uniting surfaces are broadened, 
and the adhesions are thereby increased in resisting power ; superficial 
insertion of sutures contracts the uniting surfaces, and diminishes the bulk 
and strength of the adhesions. The aim should be to get union by a sort 
of flange-stitch which opens up and broadens the surfaces to be united. 

Dressings. — Any dressing that is aseptic and absorbent will do. As a 
routine dressing I sprinkle a little boric powder around the wound, and then 
rub it into the skin with the fingers holding a few drops of carbolic lotion. 
Thus any germs that may be lurking in the hair-follicles, or amongst 
the epidermic scales, are rendered inert if not destroyed. Then a strip 



894 SYSTEM OF GYNAECOLOGY 

of boric lint of four thicknesses is laid over the wound, and the whole 
is covered with long strips of strapping. Primary healing is practically 
universal ; " stitch abscesses " are almost unknown. At the end of a 
week the wound is healed ; but the stitches, if of silk-worm gut, may 
with propriety be left in for three weeks until the young cicatricial tissue 
has gained density and strength. I believe that buried sutures are of 
value chiefly because we cannot remove them; they keep up perfect 
apposition for about three weeks till they are absorbed. By leaving in 
ordinary sutures for three weeks we get this advantage. 

Many varieties of dressing have been described. One of the best is 
that of Howard Kelly, which hermetically seals the wound and prevents 
the invasion of micro-organisms from without. He thus describes it (1) : — 

''After closure of the incision, the skin, the line of the wound, and 
the sutures are dried, and two layers of sterilised gauze or cheese-cloth, 
large enough to project from two to four inches beyond the incision on 
all sides, laid on the skin. This is saturated with the following adhesive 
mixture, which is evenly distributed over the whole surface : Squibb's 
ether or washed ether and absolute alcohol, equal parts ; bichloride of 
mercury, enough to make the solution yb^o^o" ? snowy cotton (Anthony's), 
enough to make a syrupy consistence, added in small pieces, stirring. As 
soon as this is poured over the wound evaporation takes place, and the 
celluloidin hardens, gumming the gauze fast to the skin. To avoid delay 
in waiting for this to grow quite hard, and to prevent adhesion to the 
cotton applied above it, the whole surface is freely dusted over with a 
finely powdered mixture of iodoform (one part) and boric acid (seven 
parts). The wound thus sealed with celluloidin may be left untouched 
for a week or more, when the dressing should be softened with water (or 
more rapidly with ether), the gauze lifted off, and the stitches taken out." 



Variations in Method of Operating according to the Nature and Position 

of the Tumour 

In Dermoid Oroivths. — The contents of dermoid tumours may be 
cheesy and thick, and refuse to run through the trocar. In such cases the 
best practice, if the growth be not very large, is to prolong the incision 
and deliver the tumour bodily. If the tumour is large, the whole space 
surrounding the tumour is packed with flat sponges ; the two sides of the 
puncture in the cyst are caught by large catch-forceps and pulled forwards 
on the sponges, and the contents are then squeezed out by pressure on 
the parietes, assisted possibly by the fingers or hand inserted into the 
tumour cavity. The most scrupulous care should be taken to prevent 
escape of any of the sebaceous contents into the abdominal cavity. The 
greasy material once in the cavity is difficult to remove, and a small 
quantity left inside may be the source of peritonitis. Pure dermoid cysts 
are not often of large size ; these cysts are, however, often of a mixed 
kind, and then may reach large dimensions. Dermoids would seem to be 



OVARIOTOMY 895 




more liable to rotation of the pedicle, even to the extent of complete 
separation, than other varieties of ovarian growth. 

In Solid Tumours. — In the removal of solid tumours of whatever 
nature a long incision is necessary. For help in delivery, the insertion 
of a myoma-screw (Fig. 241) into the 
substance of the tumour may be of as- 
sistance. The force of suction is over- 
come by inserting the fingers between 
the tumour and the deep parts so as to 
admit air. When the tumour is de- 
livered a large sponge or diaphragm is 
placed in the cavity over the bowels to 
prevent their extrusion. The pedicle 
in these cases is often very vascular and 
fleshy; it does not often include the 
Fallopian tube. The vessels being very 
thin walled are liable to be torn by 
transfixion, even with a blunt instru- 
ment; therefore unless the pedicle be 

thick and fleshy, a single encircling Fig. 241. -screw for aiding in the delivery 
y' if,, ,. , . of solid tumours. ^ size. 

ligature is admissible. The pedicle is 

first compressed by powerful forceps at the site of ligation. While 
the ligature is being tightened the tumour is cut off by scissors, every 
cut by the scissors permitting the ligature to be drawn more tightly ; 
when division is complete the absence of bleeding from the divided 
surface shows that sufficient constriction has been exerted, and the knot 
is tied. If the pedicle be thick, a chain interlocking ligature, placed as 
already described, must be employed. 

The rare papillomatous tumours of the ovary are removed in the same 
way as solid tumours. As they bleed freely on being handled, and as 
fragments of the papillary tufts are liable to be broken off and may 
infect the peritoneum, it is well to surround the tumour by a sponge- 
cloth before it is handled ; and to carry out all manipulations w^hile the 
tumour is wrapped up in the cloth. 

I71 Tumours growing between the Layers of the Broad Ligament. — Cer- 
tain tumours having origin in the ovary, the paroophoron and the parova- 
rium, are liable to develop between the layers of the broad ligament. 
An ordinary cystoma may do this; it is then known as " encapsuled." 
Tumours originating in the parovarium — simple parovarian cysts — may 
be encapsuled. Papillomatous cysts, which undoubtedly frequently origi- 
nate in the paroophoron or hilum of the ovary, are very frequently encap- 
suled ; that is, they grow between the layers of the broad ligament, and 
open them up. Soiiie cases have half the cyst outside and half inside the 
peritoneal covering; some are completely enveloped. Papilloma-bearing 
cysts may present many difficulties in removal. 

A tumour, opening up the broad ligaments and covered by peritoneum 
and its underlying areolar tissue, has a pink opaque surface, very different 



896 SYSTEM OF GYNECOLOGY 

from the white or gray glistening surface of the wall of a cystoma. It 
is tapped as usual, and, as far as possible, delivered. There will be no 
proper pedicle ; the whole length of the broad ligament may be involved, 
and the growth may dip deeply into its substance. 

In the enucleation of all these tumours two practices may wisely be 
followed : firstly, to begin by tying off as much tissue as possible at the 
uterine cornu, this will check all bleeding coming from the anastomosis 
between the uterine and ovarian arteries, which is the chief blood-supply ; 
and, secondly, to do as little enucleation as possible, but instead to carry 
division of the broad ligaments well down into the pelvis. It saves 
bleeding to cut off the utero-ovarian blood-supply from the beginning. 
It saves time, and removes superfluous and perhaps dangerous tissue, to 
cut away with the tumour large flaps of the spread-out broad ligaments. 
It is waste of time to separate flaps of peritoneal tissue from the tumour- 
wall when both are to be removed. 

In such cases a ligature is placed, by transfixion with the bent pedicle 
forceps, between the uterine cornu and the tumour; then the areolar 
tissue beyond the ligature is opened up. Guided by the forefinger, the 
peritoneum is divided in a line leading as nearly as possible straight 
between the cornu and the pelvic attachment of the broad ligament. 
Catch-forceps are placed on the bleeding points as they appear, and are 
left attached till enucleation is complete, when they may be replaced by 
ligatures if necessary. Usually, however, forcipressure for a few moments 
will be found sufficient to check all the bleeding. When a beginning 
is made, enucleation may usually be carried out very rapidly by the 
fingers, an adhesion here and there being caught in forceps and 
divided. 

The raw surfaces left after enucleation should be covered in by 
suturing together the peritoneal free margins, otherwise bowels will 
become adherent to them, and obstruction may ensue. The danger of 
the formation of a hsematoma between the layers of the ligaments is 
avoided by securing perfect hgemostasis, and perhaps by placing a small 
rubber tube in the cavity, and taking it out at the bottom of the parietal 
incision. It may be removed in twenty-four hours. 

In some of these cases, more especially of the papillomatous variety, 
the whole of one side of the uterus, or even of both sides, may be entirely 
denuded of ligaments. In such a condition the checking of bleeding 
from the uterine vessels may require many ligatures, or even, as I have 
found, the application of the actual cautery. 

Ovariotomy during pregnancy requires no special description for 
the early stages. In the later stages of pregnancy, if the tumour be well 
to one side and the uterus to the other, a lateral incision over the probable 
position of the pedicle will cause less disturbance of parts and give easier 
access than a median incision which necessitates some lateral displacement 
or even rotation of the uterus. Special care is given to the ligation of 
the pedicle which may contain large vessels. The operation in every case 



OVARIOTOMY 897 



should be performed with, as little disturbance of parts as possible, so as 
to lessen the tendency to abortion. 

Incomplete Operations. — The number of incomplete operations, 
instead of diminishing as we might expect, seems to be on the increase. 
We should expect their number to diminish because early diagnosis and 
early operation have made ovariotomy an easier operation than it Avas 
thirty years ago, when late diagnosis was more common, and delay until 
the patient could not walk was the rule. One experienced surgeon 
records no less than twenty per cent of unfinished operations, another 
three per cent. These cases are sometimes complacently put down as 
"recovered," — more truly it might be said of them, "abandoned to death." 
In England, amongst experienced operators, it is the rarest possible 
event to have an incomplete ovariotomy. In a personal experience of 
over two hundred operations, with no case refused, I have never left an 
operation incompleted. If, as most experienced surgeons insist, there 
is no cystic growth of the ovary which cannot be removed, a heavy re- 
sponsibility rests on the surgeon who fails to complete the work he has 
begun. Deaths are certainly most numerous after the most desperate 
operations ; these operations ruin statistics, but they save lives. In the 
belief that the interests of our patients and of surgery are best served 
by the completion of an ovariotomy once begun, I make no attempt to 
formulate rules for guidance in the case of operations left unfinished ; 
nor any attempt to classify unremovable tumours, because, in the opin- 
ion of those most competent to judge, there are no such tumours. 

Accidents — Complications. — An ordinary ovariotomy is one of the 
most straightforward and precise of operations, in which nothing but 
ignorance or want of experience can lead to error. But extraordinary 
cases are constantly met with in which unusual conditions lead to par- 
donable accidents. The most common of these may be described. 

Extrusion of Boivels. — Through straining of the patient or sudden 
delivery of a tumour, intestinal coils may escape from the cavity and 
roll out over the abdomen. If the surgeon is engaged in other important 
work, it is the assistant's duty to prevent this by timely placing of 
sponges, or by the insertion of MaunselPs diaphragm. During delivery 
of a tumour the surgeon's left hand will instinctively seek to prevent 
extrusion of bowels. A^Tien many coils have escaped they are at once 
covered by a sponge-cloth ; the forefinger of the assistant is hooked in 
under the top of the incision to pull the parietes well forward, while 
the surgeon, with both hands spread over the sponge-cloth, compresses 
and empties the intestines, and then slips them inside. A recurrence 
of the accident is prevented by the insertion of a suture in the wound, 
or by placing sponges or the artificial diaphragm. 

Stripping the parietal peritoneum from the parietes in the belief 
that an adherent cyst-wall is being separated, is an accident that may 
happen to inexperienced operators. If the patient is thin there may 

3 m 



SYSTEM OF GYNECOLOGY 



be but little subperitoneal fat, and the peritoneum may be so loosely 
attached that it readily peels off. The whole anterior parietes may 
thus be denuded by reckless manipulation. If the peritoneum be very 
thin and has been roughly handled, it had better be removed than left 
to the risk of gangrene. Occasionally separation of a very thick peri- 
toneum adherent to a suppurating or gangrenous cyst is accidentally 
made. It is better to do this than to tear the cyst-wall, which may be 
on the point of rupturing at the seat of adhesion. Such pieces of sepa- 
rated peritoneum should be removed with the tumour. 

Rupture of the cyst-wall in any way, but especially by pushing a trocar 
right through both sides of it, need not do much harm unless the contents 
of the cyst be putrid. Frequently the walls of the cyst are so friable 
that they will not hold together' under the forceps, and tear even under 
gentle handling by fingers. In such cases it is impossible to prevent the 
escape of some of the cyst-contents, and this should be provided for by 
packing in large sponges under the tumour. We may have to operate 
for rupture of a cyst. In one such case I discovered almost accidentally, 
high up in the abdomen, a mass of gangrenous glandular tissue as large 
as the fist, which had escaped at the time of rupture and was embedded 
in adhesions. It was removed in the belief that it was an unreckoned 
sponge. Solid glandular masses may similarly escape during operation 
in cases of rotten cysts. Such rents may sometimes be closed by forceps. 
Complete delivery of the tumour is, however, the end to be aimed at; 
while during the manipulation it must be as completely isolated by 
sponge-packing as adhesions will permit. Irrigation will be called for 
in these cases. 

Hcemorrhage to an alarming extent may be caused by injury to the 
walls of a very vascular tumour, or of one of the large pelvic or mesen- 
teric vessels, or by division of vessels in adhesions. If bleeding from 
the cyst-wall is very free, and the tumour, on account of adhesions, 
cannot at once be delivered, a large pressure-forceps, placed temporarily 
on the pedicle, will check the bleeding for the time. I have met with 
a general varicose condition of the omentum and anterior parietes in a 
case of solid ovarian tumour, in which very free bleeding took place on 
handling. The occurrence of bleeding from injury to any of the iliac 
veins is a very serious accident, and difficult to deal with. A wound in 
a large vein may be sutured ; a small vein should be tied on both sides 
of the wound or tear. General oozing from a large denuded surface 
may be controlled by firm pressure with sponges or gauze. Occasionally 
styptics, or the actual cautery, will be required. Haemorrhage, after 
operation, is usually from an imperfectly secured pedicle : this, if in any 
quantity, requires reopening of the abdomen and satisfactory ligation. 
Effused clot will be removed and the cavity cleansed by sponging or 
irrigation. A drainage tube, inserted for a few hours, will add to the 
security. 

Injuries to the hollow viscera may occur under the most skilful 
management, and are sometimes unavoidable. In every case they are 



OVARIOTOMY 



serious, and should be dealt with at the earliest possible moment. 
Intestine is usually lacerated during the separation of old dense adhe- 
sions, when the bowel is embedded in a deep sulcus between two cysts. 
It should be sutured at once by Lembert's or Dupuytren's method. 
The vermiform appendix is sometimes embedded in a sulcus, and firmly 
adherent ; it is best to amputate it at once, and not to attempt to sepa- 
rate it from the tumour. 

Injury to the walls of the bladder are more common than complete 
laceration. The latter condition, of course, demands accurate suturing. 
If the injury, while not penetrating the mucous membrane, involves the 
muscular coat to any extent, it is wise to place some puckering sutures 
for safety. Rupture of the gall-bladder is a rare injury during ovari- 
otom}^ ; the rent should be closed at once, and special gauze drainage 
provided through a separate opening. 

The ureter is liable to accident, either by inclusion in the pedicle- 
ligature or by division. If the ureter be divided, and the accident 
discovered at the time, it is best to unite it at once by the operation 
known as uretero-ureterostomy. If the injury be discovered later in 
the progress of the case, either operation, or the implantation of the 
ureter into the bladder, may be carried out. The full management of 
the case in such a condition cannot here be detailed. 

Lrjuries to the solid viscera — liver, kidney, or spleen — are not 
usually of serious moment. They are mainly of the nature of peri- 
toneal denudations done during the separation of adhesions, and are 
dangerous only when there is excessive bleeding. The use of the actual 
cautery, or a solution of perchloride of iron, will usually be effectual in 
checking the bleeding ; if these fail, gauze packing may be employed. 

Foreign bodies left in the cavity — sponges, forceps, or other instru- 
ments — have caused a good many deaths after ovariotomy. Preven- 
tion is the best remedy here ; instruments and sponges, before and after 
operation, should always be accurately counted. As soon as it is cer- 
tain, or even probable, that a foreign body has been left inside, the 
abdomen should be reopened and the body sought for and removed. 

Intestinal obstruction, following ovariotomy or oophorectomy^, arises 
in most cases from adhesion of bowel to the stump of the divided 
pedicle. The false obstruction, arising from the intestinal paresis 
which accompanies peritonitis, is considered under treatment after 
operation, and need not here be dwelt upon. 

About two per cent of all the deaths after ovariotomy are caused by 
obstruction, induced by kinking of a loop of bowel which has become 
adherent to the raw end of the divided pedicle. This accident is most 
liable to occur after removal of the appendages for myoma. Here the 
restricted space between tumour and parietes, in which bowel is caught 
and compressed, both disposes to the accident and aggravates the result 
of it. Traction of the adherent gut produces kinking, and this is, in 
most cases, the final cause of the obstruction. 

Obstruction may be caused by the bowel getting caught in the 



900 SYSTEM OF GYNECOLOGY 

pedicle-ligature, or in a parietal suture. Holes left in omentum, mesen- 
tery, or broad ligament, may cause obstruction if the bowel slip through 
them and get entangled. 

The symptoms of obstruction vary with the cause. In ordinary 
cases, caused by adhesion of bowel to pedicle, the symptoms come on 
at some period between the third and fifth day, and are of the ordinary 
character met with in non-operative cases. Vomiting, abdominal dis- 
tension, insuperable constipation, and more or less collapse, may be 
expected. Where bowel is caught in a ligature the symptoms come on 
at once, and quickly become serious. It requires some experience and 
keenness of insight to diagnose intestinal obstruction with certainty 
after ovariotomy. 

As soon as the condition is diagnosed the abdomen should be re- 
opened and the gut liberated. Entrance may be made through the 
healing incision, by separating the adherent margins of the wound by 
finger or blunt dissector. If the cause is at the seat of the parietal 
incision it is removed almost on discovery. If at the pedicle, the bowel 
and pedicle are brought to the surface and separation is made under 
view. The adhesion in such cases may be very close and intimate ; and, 
if intestinal wall is likely to suffer much injury in the separation, it is 
better to shave off a piece of the stump and leave it attached to the bowel, 
than to incur any risk of rupturing the intestine by separation. Any lac- 
eration of gut should be closed at once by a Lembert or Dupuytren suture. 

After Treatment. — Nothing in the whole range of surgery is more 
remarkable than the ease and rapidity with which a patient recovers 
after an ordinary ovariotomy. If we let the patient alone, and do not 
worry her with fussy regulations and injudicious applications of tenta- 
tive therapeutics, she will probably feel perfectly well on the third or 
fourth day. She may lie in any position she likes, on back or side ; 
she may pass water when she desires, and need not do so before; and 
within wide limits she may drink what she likes, provided it is not 
cold and is absorbed by the stomach. To keep the patient in the supine 
posture, to draw the water at stated intervals, and to starve the patient 
of all liquids are quite unnecessary in the majority of cases, and cause 
suffering in not a few. Comfort is a therapeutic measure of real im- 
portance, and we should do everything possible to promote it. We 
should look with suspicion on any adjuvant to surgical healing which 
causes discomfort or suffering to the patient. 

One of the most common complaints after ovariotomy is backache. 
The causes of it are various : the strain of keeping straight on a hard 
mattress a back which is naturally curved is probably one cause ; it is 
certain that to turn the patient first on one side and then on the other 
affords most relief. A hot rubber-cushion or water-bottle under the 
sacrum often removes the aching. Changing the patient from one bed 
to another, with clean fresh linen and well-shaken mattress, is a luxury 
which is always highly appreciated. 



OVARIOTOMY 901 



Thirst in this, as in most other abdominal operations, is nearly always 
present. Some surgeons withhold all liquids by the mouth for the first 
twenty-four or forty-eight hours ; this aggravates the thirst, sometimes 
almost to torture. If there be special reasons for withholding liquids 
by the mouth, a pint of hot water, administered slowly by the rectum, 
will relieve the thirst ; and a second administration, after six hours, will 
probably remove it. But in ordinary cases liquids may be given by the 
mouth almost from the beginning. Most women prefer hot tea made to 
their own taste, and with it a little dry toast may be given. Gruel, 
one of the ordinary children's foods such as Benger's or Mellin's, 
barley water or toast water, or almost anything the patient likes, except 
milk, may be given by the mouth. On the second day home-made beef 
tea, or any of the concentrated beef essences, may be given, well diluted. 
Often on the third, nearly always on the fourth day, the patient may be 
permitted to order her own diet. After the fourth day solid or con- 
centrated foods are preferable to liquid and very dilute foods ; they 
produce less flatulence, and are usually liked better. Fish, chicken, 
game, boiled or stewed, and not roasted, may be given on the fourth 
day ; and thereafter the diet scarcely requires regulation. Fruit of all 
sorts may be given throughout. Milk is not a good food after abdomi- 
nal operations; it causes flatulence and promotes constipation, or rather 
permits it. 

The functions of the bladder require special attention. It used to 
be the custom to draw the urine off by catheter at regular and stated 
intervals after operation, whether the patient desired it or not. This is 
not necessary. As a rule the catheter need not be passed till the patient 
desires to micturate, and then, if she can, she may be permitted to do so. 
It is rarely necessary to interfere during the first twenty-four hours. 
The amount of urine secreted is diminished considerably after ovari- 
otomy, and remains under the normal for about a w^eek. On the first 
day about 15 ounces, on the second 20, on the third 26 may be expected. 
Therefore, if the patient cannot herself micturate, one passing of the 
catheter on the first day, two on the second, and three on the third and 
subsequent days, should suffice ; unless there be a desire for relief on the 
part of the patient. To avoid catheter-cystitis strict attention should be 
given to the purification of the orifice of the urethra and of the catheter. 
A metal catheter, wdiich can be sterilised by boiling or heat, is safer 
than a catheter of soft material which cannot be so treated. Catheter- 
cystitis, which is simply septic cystitis, may be very troublesome, lasting 
over weeks ; therefore, strict personal attention should be given to this 
item in the treatment. 

At the end of the second or third day the bow^els should be evacuated. 
Ordinarily this is best secured by a soap and turpentine enema. 
Usually great quantities of gas come away wath the enema, and the 
abdomen becomes flat or concave. A seidlitz powder, given the first 
thing in the morning of the third day, if the patient can take it, will 
have an equally good, or even a better effect, if it acts ; but it is some- 



902 SYSTEM OF GYNAECOLOGY 

what uncertain. On the third or fourth day an active purge of colocynth 
may be administered. Thereafter the bowels are kept acting by any 
means the surgeon considers suitable. 

These remarks refer to the ordinary progress of an uncomplicated 
case. A serious operation is followed by a serious illness of the kind 
which follows all grave operations, and it is treated on the same prin- 
ciples. Such an illness, classed under the broad term " shock," is soon 
over. Specially dogging the graver operations, but also sometimes fol- 
lowing ordinary ones, is a complication of troubles which are often 
classed vaguely as peritonitis, and which present themselves as abdomi- 
nal distension, obstruction of intestines, and vomiting. 

Severe shock or collapse after operation is combated by the appli- 
cation of heat to the body surface ; by elevation and bandaging of the 
limbs; by hypodermic injections of ether; and by rectal injections 
containing brandy. Irrigation of the cavity with water heated to 105° 
or 110° F. has been spoken highly of as treatment of shock. Near the 
end of a bad operation it is good practice to administer a four-ounce 
rectal injection, containing an ounce of brandy; and to repeat this every 
four hours till the patient is out of danger. Hypodermic injections of 
strychnine are spoken highly of by some surgeons, not only as helping to 
prevent shock, but also as causing contraction of the intestines. Mor- 
phine is not to be administered except in cases of great restlessness or 
jactitation; then it is of real value. The objections to it are the gaseous 
distension of the intestines, and, in some patients, the nausea and vomit- 
ing which it produces. After every serious operation it is wise to begin 
rectal feeding at once, and this should be continued until the patient, 
v/ithout losing ground, can get on with nourishment taken by the 
mouth. 

The condition which is most dreaded after ovariotomy has been 
vaguely, perhaps inaccurately, but conveniently described as originating 
in peritonitis. The exact pathology of the condition is not ascertained ; 
probably it has several causes, not one of which may be peritonitis. It 
manifests itself by three almost uniform signs — vomiting, abdominal 
distension, and constipation. Whatever be the prime cause, our only 
means of curing the disease is by fighting the symptoms. 

Extensive and serious injury to the peritoneum is probably followed 
by peritonitis. A traumatic peritonitis, with abundant exudates, pro- 
vides a convenient medium for septic invasion. Thus, though it practi- 
cally happens that septic peritonitis is chiefly associated with traumatic 
peritonitis, they are not necessarily connected; the one may exist with- 
out the other. If the patient gets well we cannot say whether it has 
been septic or traumatic ; it may have been both. After death the diffi- 
culty is little less ; post-mortem peritoneal fluids are culture media for 
all contiguous intestinal germs, and their presence in peritoneal exudates 
after death is no certain proof of their presence during life. 

As yet we can only treat the disease by meeting its manifestations. 

The first symptom we have to deal with is vomiting. Arising after 



OVARIOTOMY 903 



recovery from the anaesthetic, and continuing over the first day or two, 
it may Idc nothing more than anaesthetic sickness ; continuing over the 
third or fourth day, or beginning on the third and continuing, it means 
something more, and is of grave moment. It is useless to seek to con- 
trol it, nor is it wise to attempt to do so. Vomiting relieves over-dis- 
tended intestines, and should be encouraged rather than repressed. The 
stomach should not be worried with food ; this simply adds to the labour 
of rejection: none of it is absorbed. 

As soon as vomiting has set in the patient should be fed entirely on 
stimulating enemas. A good routine enema is an ounce of brandy, two 
drachms of concentrated beef jelly, and milk, peptonised or not, up to 
four ounces. Not much milk is absorbed, but it acts as a diluent, and is 
well tolerated by the rectum. Once in the day, at least, a large turpen- 
tine enema should be given ; it will bring away quantities of gas and un- 
absorbed and putrefying residues of food, and will cleanse the large 
bowel : the turpentine has probably some antiseptic influence as well. 
Constant vomiting of small quantities is very exhausting to the patient, 
and is often associated with over-distension of the stomach ; in such a case 
it is often good treatment to pass the stomach-tube and empty the stomach. 
If the stomach be not over-distended, but vomiting frequent, it may do 
good to give a, large drink of soda-water, so as to encourage one attack 
of free vomiting. A period of rest often follows such treatment. 

Usually associated with the vomiting is tympanitic distension of the 
intestines. The condition is well named " Pseudo-ileus." It is a form of 
intestinal obstruction without a mechanical, or at any rate a constricting 
cause. The influences at work in the production of pseudo-ileus are 
probably varied ; certainly one of them is a condition of intestinal paresis 
whereby stasis of intestinal contents is produced. If we can overcome 
this condition, if we can make the intestines act, we shall probably cure 
the patient. This has been written and spoken of as the treatment of 
peritonitis by purgatives, and many arguments have been used for and 
against the treatment. It is probably not so much the peritonitis as the 
paretic ileus which is attacked and cured by purgation. When the latter 
is removed the former cures itself. It is certain that a sharp purge will 
often put a completely new aspect on a case which is drifting hopelessly 
on to death with tympanitic distension and vomiting. Enormous 
quantities of gas and fluid faeces are passed ; the abdomen, before dis- 
tended and brawny, becomes flat and soft ; vomiting ceases ; and the 
patient expresses a sense of relief which usually culminates in refreshing 
sleep. There is probably no single effect of a drug in the whole of 
surgical practice more strikingly beneficent than this one of a purge in 
operation-ileus. For mild cases a seidlitz powder will usually suffice. 
For more severe cases a full dose of colocynth and jalap, or a calomel 
powder may be given. The treatment of the full consequences may well 
be carried into the beginnings of the trouble. In other words, we may 
wisely keep the bowels acting almost from the beginning. If the routine 
turpentine enema fail to keep the abdomen flat a purgative should at 



904 SYSTEM OF GYNECOLOGY 

once be given by the mouth ; and this should be repeated once or twice 
while there is any marked tendency to distension. 

An invaluable adjuvant in the treatment of flatulent distension is 
the passing and wearing of the rectum tube. The vaginal tube Avhich 
accompanies a Higginson's syringe does very well for the purpose, and 
is a good model as regards size and length for any specially made tube. 
It is best used with the patient on her side, and the hips raised so that 
the gases rise to it. The intestines contract at intervals ; the large 
bowel may be emptied in the first few seconds ; then after a minute or 
two more gas comes into it from the small intestines, and is passed ; 
then after another interval more gas is passed, and so on till the abdomen 
becomes flat. It is a good plan to let the patient wear the rectum tube 
for half an hour before the enema is due, to pass the enema up the tube, 
and then to remove it. A skilled nurse will be able, by judicious intro- 
duction of the rectum tube, to render most important assistance in the 
recovery of the patient. 

The pyrexia which follows ovariotomy scarcely ever requires treat- 
ment. In simpk cases there is usually a rise to 99-5° or 100° F. on 
the second day, and this usually falls to normal on the third or fourth 
day. In bad cases there is rarely any rise at all ; in the worst cases, and 
especially those with septic peritonitis, the temperature is usually sub- 
normal till just before death, when it rapidly rises. So rare is a danger- 
ous rise of temperature that no provision need be made to deal with it. 

Rare and special complications scarcely require mention. The most 
common of them is parotitis. Mania occurs in a very small proportion 
of cases. Intestinal fistula caused by injury to bowel at the operation, 
or by pressure from a drainage tube, may spontaneously heal, or may 
require operation. The occurrence of ventral hernia as a late result 
should be very rare in ovariotomy if the closure of the parietal wound 
is skilfully effected. Its treatment is outside the scope of this paper. 

Removal of the Uterine Appendages (Oophorectomy : Salpingo- 
Oophorectomy) . — By this operation is meant removal both of ovaries 
and Fallopian tubes for disease other than neoplasm. The operation 
may be undertaken : I. When the appendages and the uterus are normal ; 
II. When the uterus is affected with myoma ; III. When the appendages 
are in a state of inflammation. Variations in the method are described 
under these headings. A short account of conservative operations on 
the ovaries and tubes is added. 

The operation is prepared for as in ovariotomy ; and all details as to 
room, assistance, anaesthesia, and nursing are identical. The Trendelen- 
burg posture is much preferred by some surgeons for this operation. 

The instruments also are the same, except that tapping trocars and 
numerous large cyst-forceps are not called for. Two pairs of large el- 
bowed pressure-forceps and a dozen ordinary catch-forceps are necessary. 
In cases where the appendages are bound down by numerous and firm 
adhesions in Douglas' pouch, the rectal bag, as used in supra-pubic cystot- 



OVARIOTOMY 905 



omj, may be found very useful for raising the field of operation nearer 
to sight and touch. 

Operation icith Appendages and Uterus Normal. — The incision, which 
need not be longer than an inch and a half or two inches, is made in 
the middle line a little nearer to the pubes than to the umbilicus. The 
tissues divided are the same as in ovariotomy. As, however, the parietes 
are not stretched by tumour, the linea alba is narrow ; and one or other 
rectal sheath will probably be entered. The peritoneum when exposed 
is picked up between two peritoneal catch-forceps and pulled forwards ; 
the fold between them is sawed through by a knife held horizontally ; 
air rushes in when the cavity is opened, and the bowels fall back. The 
left forefinger inserted through the opening serves as a guide on which 
to divide with scissors the peritoneimi to the whole extent of the parietal 
wound. 

The first and second fingers of the left hand are now inserted into 
the cavity, and are carried straight down to the pelvis. It may be nec- 
essary to push omentum upwards. The fingers, displacing intestines 
which are in the way, seek for the fundus uteri, and grasping the fun- 
dus between them, they are slipped along one or other broad ligament, 
gathering Fallopian tube and ovary in their grasp, and holding them 
there. These are now lifted out through the parietal wound, and 
arranged for application of the ligature. The parts to be removed are 
the ovary, with its mesovarium, and the Fallopian tube in its outer 
three-fourths, with its double fold of peritoneum or mesentery; in 
which also lie the parovarium and the vascular tissue known as the 
bulb of the ovary. 

The ligature is placed by transfixion. The Staffordshire knot is per- 
fectly satisfactory and easily applied. The pedicle-forceps (Fig. 232) is 
passed through the broad ligament under the ovary at the point selected, 
and catches the loop of silk ligature, placing it in withdrawal. Or the 
ligature may be passed threaded in a blunt needle. The loops being 
arranged as already described for ovariotomy (p. 889), the fingers of 
the left hand pull ovary and tube well through them, Avhile the ends are 
pulled as tightly as possible by the right hand. Pressure between the 
left finger and thumb around the seat of ligation, combined with traction 
on the ends of the ligature, serve to bury the ligature in the tissues ; then 
it is tightly tied in the usual way. Forceps or the fingers of an assistant 
are quite unnecessary ; the whole may be done in a few seconds by the 
surgeon unaided. The parts are then cut away by scissors at a distance 
of about one-third of an inch from the ligature. Before division is 
complete a catch-forceps may be placed on the stump to make certain, 
by pulling it to the surface, that hsemostasis is perfect before closing 
the wound. The same steps are carried out with the appendages on the 
opposite side. 

Then a small sponge is placed under the parietal opening, the sutures 
are inserted, the sponge is removed, the stumps are pulled up by their 
attached forceps, looked at, and if well secured, are dropped into the 



9o6 SYSTEM OF GYNECOLOGY 

cavity, and the sutures in the parietal wound are tied. The wound is 
dressed as in ovariotomy. 

Operation for Uterine Myoma. — In the case of small tumours the 
operation may be the same as that just described with normal uterus. 

Where the tumour is large or fixed in the pelvis, or where, being in 
the fundus, it grows away from the appendages, the operation may 
present considerable difficulties, or may even be surgically impossible. 
In unsymmetrical tumours one ovary may be near to the surface and 
quite within reach, while the other lies deeply or out of reach. In all 
cases, therefore, before removing the appendages on one side we should 
ascertain if the appendages on both sides can be removed. It frequently 
happens that an ovary is much stretched, and so attenuated as to be 
almost undiscoverable ; sometimes it is almost buried in the sulcus 
between two growths. 

When it has been decided to remove the appendages, the tumour 
is turned to one side so as to bring them as close to the surface as pos- 
sible. At this stage it may be advisable to prolong the incision upwards 
or downwards as may seem more convenient. In most cases the incision 
will have been made longer than for cases with normal uterus. If pos- 
sible the Staffordshire knot is used : but, if the ovary be much spread 
out, a double or triple interlocking ligature may be preferred, as it 
is possible thus to get more thorough constriction over a larger area. 
Forceps are left attached to the pedicle first made while the uterus is 
turned to the opposite side, and the alternate appendages are removed. 
A sponge placed over the pedicle prevents disturbance by friction, and 
calls attention to the existence of bleeding. 

It would seem that intestinal obstruction from adhesion of bowel to 
stump, and consequent kinking, is more liable to follow removal of the 
appendages for myoma than for other disease. The intestine seems 
liable to get caught between tumour and pelvic wall, or at least does not 
freely move about there ; and thus the formation of adhesions is favoured. 
To avoid this, the stump may be turned face-inwards on the tumour, and 
held there by a stitch; its raw surface then becomes adherent to the 
tumour : or it may be covered up by a flap of peritoneum left hanging 
beyond the actual line of division. 

Operation ivith Appeiidages inflamed and adherent. — Eemoval of the 
uterine appendages, when matted together and adherent to neighbouring 
organs, and perhaps containing one or more collections of pus, may be 
a very difficult operation. A good many cases are recorded vv^here the 
operation was either abandoned as impracticable or was left incompleted. 

The operation is performed either by the help of sight or by touch 
alone without exposure to view. If the diseased organs are to be 
exposed to view, a long incision and either evisceration of intestines, 
or pushing them into the upper abdomen, are necessary. For this the 
Trendelenburg posture with great elevation of the pelvis should be 
adopted. The use of the rectal bag to raise the pelvic floor is also of 
assistance. Strong retractors, or Maunsell's self-acting retractor, are 



OVARIOTOMY 90? 



necessary to keep tlie parietal incision open ; and artificial light Avith 
or without concave mirrors may be required. 

This method of operating has not found favour in England. If the 
parietes are muscular and hard, it is not easy to crowd the intestines 
into the upper abdomen ; and considerable force may be required to keep 
the incision sufficiently open to give a fair view of the parts while 
manipulation is going on. The incision itself must be of considerable 
length, five or six inches perhaps ; and this means in an undistended 
abdomen that it reaches the umbilicus, or even rises above it. 

It is best to depend entirely on the fingers for removal of adherent 
appendages. The skilled sense of touch is a safe guide against the risk 
of tearing bowel or other attached structures, and the fingers are strong 
enough to detach any adhesions which are likely to be met with. 

The incision is made in the ordinary way, and may be about three 
inches in length. A little cloudy or pink serum often appears in the 
incision ; not unfrequently there is a considerable amount of ascites. 
The first and second fingers of the left hand are carried to the fundus 
uteri, thence into Douglas' pouch, and along both broad ligaments ; and 
the state of affairs accurately made out. If there be any collections of 
fluid, purulent or sanguineous, it is wise at once to place a flat sponge 
in the pelvis to prevent contamination in case the cyst-wall is ruptured. 
It is often almost impossible to separate and deliver entire an abscess 
with very thin walls ; a sponge to surround the field of operation 
minimises the risks from rupture and diffusion. 

The work of separation is now begun. Detachment is begun from 
below, the inflamed organs being unfolded upwards as the adhesions are 
separated. The firmest adhesions are usualh^ to the posterior surface 
of the broad ligaments, and here bleeding is likely to be most free. 
Adhesions to the rectum must be separated with great care to avoid 
laceration of the wall of the bowel. 

The presence of the rectum bag moderately distending the gut guides 
the finger in its movements, and helps to give some idea of the thickness 
of its wall from which the organs are being detached. Adhesions to 
the uterus are more easily managed, although the bared surface may 
bleed freely. Into the spaces made after detachment the sponge is 
dragged, or new sponges are placed. This sponge-packing is a measure 
of safety in case of extravasation, a guide to a source of bleeding, and 
an absorbent of blood. It is also useful as a haemostatic. 

When the organs are detached they are pulled to the surface through 
the wound. Often they are quite sessile on the broad ligament, and 
some force may be necessary to bring them within sight. Such force 
is exerted not by dragging on the organs themselves but on their pedicle 
held between the two fingers. Liberation may be assisted by pushing 
down the broad ligament at its pelvic attachment ; tearing or stretching 
its fibres, but not wounding its peritoneal envelopment. 

Frequently the pedicle must be tied at some distance from the surface. 
By depressing the parietes and pulling the organs well up into the wound 



9o8 SYSTEM OF GYNECOLOGY 

this may usually be done within sight, but sometimes the pedicle must 
be tied and divided entirely by touch. The ligature is placed by trans- 
fixion and tied, as already described, either in a Staffordshire knot or in 
interlocking ligatures. The organs on the other side are detached and 
removed in the same way. 

Bleeding in these cases is sometimes very free, and occasionally 
alarming. By sponge-packing and pressure it may usually be checked 
in a few moments, and no bleeding points require forcipressure or liga- 
tion. If it continue, bleeding points should be looked for through a 
Fergusson's vaginal speculum ; or, if this means fail, the wound must be 
enlarged and the pelvic floor exposed. The Trendelenburg position is 
here of some advantage. A solution of iodine or of perchloride of iron 
may be mopped over a bleeding surface, or the actual cautery may be 
applied. Bleeding points are caught in forceps, which are left on for a 
few moments while the cavity is cleansed and the sutures are placed. 
Forceps placed on the rectum may, if too large a hold has been taken, 
result in the formation of a slough followed by fistula. 

The pelvis should be carefully cleansed by sponging or irrigation, or 
both, according to the nature and amount of extravasation. Sponging 
will usually suffice if blood only has to be removed ; indeed most of the 
blood will be removed with the sponges which have been packed into 
the wounded areas. Irrigation must be employed if fluids of a putrid 
or doubtful nature have escaped. 

Drainage is advisable in most of these cases. Through the tube 
bleeding gives timely warning of its onset ; and through it the abdomen 
can be kept dry, which in itself favours clotting and haemostasis. In 
cases of free bleeding the use of the gauze drain, or of gauze-packing, 
may be necessary. But everything possible should be done to render 
haemostasis perfect by the ordinary surgical means before having recourse 
to such uncertain methods as these. 

Keith's glass drainage-tube with open extremities is usually the best. 
The tube should reach to the bottom of Douglas' pouch, and should be 
supported by the collar outside the wound, and not by the rectum. 
Pressure on the rectum by the tube may cause the production of intestinal 
fistula. Gauze or thread capillary drains are placed inside the tube, 
and the absorbent dressing is placed over the tube enclosed in a folded 
sheet of india-rubber through which the upper end of the tube is drawn. 
The drainage-tube in most cases may be removed in a day or two ; but 
some cases require drainage for a week or even longer. 

Where there is a large pyosalpinx or ovarian abscess it is generally 
advisable to empty the fluid by aspiration before beginning to separate 
adhesions. This diminishes risk from escape of fluid, but adds to the 
difficulty of separation by fingers. 

The wound is dressed and the patient is treated exactly as after 
ovariotomy. Usually there is more pain than after ovariotomy, and 
constitutional disturbance with rise of temperature may be more marked. 
Pain severe enough to cause great restlessness or jactitation may be 



OVARIOTOMY 909 



alleviated by a hypodermic injection of morphia ; but the recovery is 
nearly always more rapid and satisfactory if morphia is withheld. 
Metrorrhagia nearly always comes on after one or two days ; this gives 
relief and requires no treatment. 

Conservative Operations on the Ovaries and Tubes. — Till the last few 
years the generally expressed opinion of the most experienced opera- 
tors — that it is best to remove diseased ovaries and tubes completely 
— has been received and acted upon. A few surgeons have recently 
maintained, and proved by records of successful cases, that destructive 
surgery is not always necessary for cure ; but that conservative opera- 
tions, leaving the organs or some part of them intact, may be followed 
by cure. This has been maintained in respect not only of inflammatory 
conditions and hernia, but also of tumours and cysts. 

In respect of tumours, Martin of Berlin, Sippel, and Pozzi have been 
the chief advocates of conservatism. If, near the hilum, a portion of 
healthy ovarian tissue be visible, this is left, and the incised surfaces 
are apposed and fixed by sutures. Pregnancy resulted in a case of 
SippeFs where one ovary affected with a small growth was so treated; 
the other ovary being completely removed for a large growth. Martin, 
in twenty-seven cases in which portions of healthy ovary were left, had 
one death and two relapses ; eight of the patients bore children after- 
wards. Pozzi, in twelve cases of resection of the diseased portion alone, 
speaks favourably of the operation. Other surgeons have mentioned 
cases, but have been cautious in drawing conclusions. 

In cases of simple cysts treatment by simple puncture, or by removing 
the whole of the cyst-walls by scissors, is undoubtedly sound. Most 
surgeons would probably agree in this practice. 

In the case of abscess there is more room for dispute. Simple 
evacuation of tlie abscess with cleansing of the abscess wall would, in 
carefully selected cases, probably be entirely satisfactory. One difficulty 
is to be certain that the abscess is single, for abscesses in glandular 
organs are liable to be multiple ; and another is to be certain that the 
abscess wall is rendered sterile. Drainage, except in large abscesses, is 
not feasible at a distance from the surface ; and if it were so employed it 
would leave the organ in a bed of adhesions which would probably beget 
chronic invalidism of another sort. The most satisfactory results would 
be in a peripheral abscess with comparatively thin walls, where the whole 
sac might be cut away, and the cavity left might, after purification, be 
closed up by sutures. A central abscess with general distension of the 
whole ovarian tissue could scarcely so be treated, and is probably best 
treated b}^ removal of the whole organ. There is, theoretically, no need 
to remove a healthy Fallopian tube with a suppurating ovary ; but experi- 
ence proves that healthy tubes with suppurating ovaries are the rarest of 
combinations. The tube is useless without its ovary ; the ligature of the 
ovarian pedicle will probably cause injury or kinking of the tube ; there- 
fore, if the ovary be removed, it is usually safer for recovery from the 



9IO SYSTEM OF GYNECOLOGY 

operation, and for the future comfort of the patient, to remove the 
tube also. 

The removal of the appendages on one side only for suppurative 
disease was tried by Tait, but given up on account of the large number 
of recurrences or relapses. Other surgeons have had similar experiences ; 
and the rule in all cases of suppurative disease of the appendages now is 
that if one set is removed so also should be the other. 

More promising results have been got in the conservative treatment 
of chronic inflammatory disease with adhesions, but without suppuration. 
Liberation of the organs with removal of long tags of adhesions and per- 
haps puncture of cysts may result in cure. In most of such cases there 
is prolapse ; to remedy this operative elevation of the ovary on the broad 
ligament by shortening its mesentery has been practised. Of the real 
and permanent value of oophororaphy or oophoropexy published records 
do not permit us to judge ; but there can be no doubt of the advantage 
of the liberation of an ovary bound down by adhesions in Douglas' 
pouch or elsewhere. 

Hernia of the apx-)endages into the inguinal or femoral canals may, 
even if strangulated, be properly treated by return into the cavity of the 
abdomen, provided the hernial openings be closed. Tubo-ovarian hernise 
are nearly always inguinal; tubal hernia is with about equal frequency 
femoral and inguinal. A strangulated tube is not unlikely to contain one 
or several collections of pus ; its return, therefore, should be carried out 
only after minute examination. A probe may be passed along it, or 
puncture or other means adopted to make certain of the absence of 
suppuration. For most cases of strangulation of tubes operation by 
removal is generally considered most satisfactory. The method of radi- 
cal cure of the hernia to be adopted need not be described. 

Tubercular disease of the tubes should always be treated by complete 
removal. 

Simple cysts of the Fallopian tubes may be cured by incision, with 
partial removal of the cyst-walls. But in respect of restoration of 
function, such an operation has no advantages over complete removal, 
and has evident disadvantages in the possibility of recurrence with 
; stenosis of the tube. 

J. Greig Smith. 

REFERENCES 

1. Chambon. Des maladies des femmes, Paris, 1784: ; and De Vextirpation des 
ovaires. Paris, 1798. — 2. Clay. Cases of Peritoneal Section for Extirpation of Diseased 
Ovaries. Lond. 1842.-3. Delaporte. Mem. de VAcad. Roij. de Chir. Paris, 1753. 
— 4. Hunter. Med. Observations Inquiries, yo\.\\. Lond. 1762. — 5. Kelly, Howard. 
Amer. Jour. Obstet. xxiv. 12, 1890. — G. King and Jeaffreson. Lancet, Lond. 1856-7, 
i. 588-590. — 7. M'Dowell, E. "Three Cases of Extirpation of Diseased Ovaria," 
Eclect. Report, Phila. 1817, vii. 242-244. (From Index-Catalogne of Library of Surgeon- 
General's office, Washington.)— 8. Martin. Deutsch. 7ned. Woch. July 27, 1893. — 9. 
Pozzi. Ann. de gyn. et d'obste't. March 1893. — 10. Sippel. Centralbl. f. Gyndk. in. 
1893.-11. Tait," Lawson. Diseases of the Ovaries, Uh ed. Birm. 1883. — 12. Wells, 
Sir Spencer. Diseases of the Ovaries, Lond. 1872; Abdominal Tumours. 7th ed. 
Lond. 1887. — 13. Willius. Stupendus abdominis Tumour. Basil, 1731. 



CHROXIC INVERSION OF THE UTERUS 911 

Special ^Yo^ks and Articles on Ovariotomy. — 1. Atlee, W. S. Diagnosis of 
Ovarian Tumours. Phila. 1873. — 2. Baker-Browx. On Ovarian Dropsy. Lond. 
1862. — 3. Clay. Cases of Peritoneal Section for Extirpation of Diseased Ovaries. 
Lond. 1842. — 4. Courty, A. Diseases of the Uterus, Ovaries, and Fallopian Tubes. 
Trans, from 3rd edit, by A. M'Laren. Lond. 1882.— 5. Doran, A. H. G. Tumours 
of the Ovary, Fallopian Tube, and Broad Ligament. Lond. 1884. — 6. Ibid. Gynaeco- 
logical Operations. Lond. 1887.-7. Keith, Skene and G. E. Abdominal Surgei-y. 
Edin. 1894. — 8. Koeberle. Sur le traitement des kystes de Vovaire. Paris IStio. — 9. 
Ibid. Manuel operatoiy^e de Vovariotomie. Paris, 1870. — 10. Lizars, J. Observations 
on Extraction of Diseased Ovaria. Edin. 1825, — 11. Peax, J. Tumeurs de V abdomen 
et du bassin. Paris, 1895. — 12. Peaslee. Ovarian I'umours. New York, 1872.— 
13. Smith, J. Greig. Abdominal Surgery, 5th ed. Lond. 1896.-13. Sutton, J. 
Bland. Surgical Diseases of the Ovaries and Fallopian Tubes. Lond. 1896. — 14. 
Tait, Lawson. Diseases of the Ovaries, 4th ed. Birm. 1883. — 15. Wells, Sir 
Spencer. Diseases of the Ovaries. Lond. 1872. — 16. Ibid. Abdominal Tumours, 1th 
ed. Lond. 1887. 

1. System of Gynsecology and Obstetrics by American Authors. Edited by M. D. 
Mann and B. C. Hirst. " Gynsecology." Edin. 1889, ii. 189 et seq. — 2. An American 
Text-Book of Gynecology. Ed. by j!' M. Baldy. Phila. 1894, pp. 594-600.-3. Clinical 
Gynaecology by American Teachers. Edited by J. M. Keating and H. C. Coe. Edin. 
1895, p. 697 et seq. — 4. Pepper's Syst. Pract. Med. " Dis. of Ovaries and Oviducts" 
(Skene), 1886, vol. iv. — 5. International Encyc. Surg. Ed. by Ashurst, Lee, 1886, 
vol. vi. 

J. G. S. 



CHEONIC INVEESIOX OF THE UTEEUS 

I:n^t:rsiox of the uterus has been a favourite theme for essays. It is a 
condition attended with considerable anxiety, impaired health, and danger 
to life. Its occurrence is far from common : eminent consultants of 
exceptional experience have never met with it ; practitioners engaged in 
large midwifery practice have never seen a case. It was found at the 
Eotunda Hospital once in 190,800 deliveries. At the Vienna Lying-in 
Hospital 250,000 births occurred without a single instance. With access 
to records of over 20,000 labours I have met with one case of recent 
inversion; and in twenty-five years' practice two instances only of 
chronic inversion have come under my own care. Possibly it has hap- 
pened without recognition, or at any rate without publication, where 
close inquiry was not practicable. 

Inversion, as the name implies, is the uterus turned inside out ; the 
lining mucous membrane becomes external, the serous peritoneal mem- 
brane internal. 

It may be puerperal or non-puerperal : in the former it is associated 
with labour or is the result of pregnancy ; in the latter it is allied with 
certain tumours or growths in the non-pregnant uterus. The puerperal 
condition is responsible for the great majority of cases, as many as 87 -o 
per cent. Most of these happen at or near the termination of labour. 
Of the 224 cases collected by Crampton, 196 are noted as having occurred 
at once ; that is, at the end of the process of confinement. It follows 



912 SYSTEM OF GYNECOLOGY 

that a division into acute and chronic is admissible, the distinction 
being based upon the completion of the involution of the uterus ; that 
is, about six weeks from the date of labour. 

In the puerperal variety, therefore, inversion of the uterus may be 
looked upon as chronic when it persists after the regenerative changes 
which are normally effected after delivery. The usual reconstitution of 
the uterus may be retarded or perverted by the conditions present in any 
given case ; but the interval of time forms a valid ground for definition 
and for treatment. Chronic inversion is a sequence, then, of the acute 
form ; and is due to failure of reduction before the time allowed for 
reparation of the puerperal uterus. Chronic inversion further includes 
cases occurring independently of pregnancy ; those which happen as a 
complication of some tumours, or of some growths in the uterine walls, 
malignant or otherwise. 

Anatomy and Pathology. — Various degrees of inversion are described. 
According to Crosse, partial inversion in its slightest degree is present 
when any portion of the entire thickness of the walls of the uterus becomes 
convex towards its cavity or interior ; although it may not be invaginated, 
or brought within the grasp of the rest of the uterus. It may accompany 
the projection of a tumour into the cavity ; thus the peritoneal space has 
been opened in dividing the base of a tumour for its removal. One horn 
of the uterus may occasionally be indented. In cases of post-partum 
haemorrhage, with a large and flabby uterus — especially where efforts are 
made by external pressure to force the uterus into contraction — we not 
infrequently find the wall to yield and partial depression to follow. This 
is more likely to occur when the hand is pressed against the uterus, 
instead of grasping it after the method of Crede. In this way, as the 
placenta is expelled, the fingers may pursue it into a hollow, which 
the contraction of the whole uterus generally readjusts at once. 

The body of the uterus may be inverted as far as the os internum ; 
or there may be complete inversion of the body through the cervix into 
the vagina, or even externally. Generally the cervix remains, forming 
a distinct fold or ridge around the neck of the inversion. This fold 
varies in depth according to the extent in which the cervix is involved. 
As a rule it is rather deeper in front than behind. When the uterus 
descends externally it is usually accompanied by inversion of the vagina ; 
the cervix also participates, and the depression formed by the ring may 
not be found. 

The form of the inverted uterus is round or pear-shaped, with a well- 
formed but smaller base. The shape varies somewhat according to the 
degree of inversion and the pressure to which it is subjected by the 
constricting ring of the cervix ; or, when lower down, by the opposing 
contact of the vaginal walls. 

The same circumstances affect the consistence and colour. It may be 
firm and tense, softer and more yielding, smoother and more velvety to 
the touch. The surface of the mucous membrane may be red, or congested 
and purple ; usually it is less pink than that of the fibroid. It may 



CHRONIC INVERSION OF THE UTERUS 913 

present ecchymosed spots, or show erosions and ulcerations wMch, in few 
instances, have formed adhesions to opposite surfaces of the cervix of 
vaginal walls. It bleeds freely when handled. When the inverted sur- 
face is exposed for any length of time to the air the mucous membrane 
may lose its normal characteristics, and become dry and wrinkled like 
that of a procident vagina. The two have indeed been confounded. 

Inflammation and even gangrene have followed the arrest of blood- 
supply and the perverted nutrition due to the incarceration; and in 
some rare instances sloughing of the inverted portion has taken place. 

The peritoneal invagination contains, at the beginning,^ the broad and 
round ligaments, the Fallopian tubes, and the ovaries. Sometimes, at the 
first rush, a loop of small intestine is drawn into the cavity. After a 
time, when contraction takes place, the ovaries and tubes recede outside 
the space ; and the margin of the opening remains as a firm ring into 
which the finger can hardly pass. It rarely happens that any adhesion 
takes place between the peritoneal surfaces, though this has occurred. 

In cases of non-puerperal origin, when the formation of the inversion 
is more gradual, part only of the Fallopian tubes and broad ligaments 
are found in the interior space. 

Mechanism of Production. — Inversion begins generally at the fundus; 
occasionally at the sides, posteriorly, or at the cervix. 

It has long been considered that enlargement of the uterine cavity, 
associated with some cause capable of exciting contraction of its fibres, 
are the two conditions essential to inversion. That the uterus often con- 
tracts irregularly, one part being firm, another relaxed, is well known. 
The state spoken of as polarity, when the fundus is contracted and the 
cervix dilated, or conversely, is an observed fact supposed to be due to 
some correlation of nerve force. 

Most authors speak of the important part taken by modifications in 
the placental site as a factor causing inversion. The wall of the uterus 
at this part is thinner and more lax ; its structure is modified ; it is 
generally more yielding and of less power. Klob says defective con- 
traction of that part of the uterine wall which forms the placental 
insertion is of extraordinary importance; and he describes it as sink- 
ing inward into the uterine cavity while other parts of the organ seem 
tolerably well contracted. 

Rokitansky speaks of paralysis of the placental insertion as originat- 
ing depressions in connection with irregular contractions of the other 
parts of the uterus. 

Matthews Duncan devoted special attention to this subject, and formu- 
lated his views respecting it with much emphasis. His views appear to 
be the outcome of a concise and logical interpretation of facts which afford 
a rational explanation of the phenomena observed. He divides inversion 
after delivery into active and passive, and describes four kinds : (A.) 
Passive : (i.) Spoyitaneous, and (ii.) Artificial. (B.) Active : (iii.) Spoyita^ie- 

1 Svensson amputated one three months after delivery, and found in the extirpated mass 
both the ovaries and the greater portion of the broad ligament (Sajous, 1889, i. p. 23). 

3n 



914 SYSTEM OF GYNECOLOGY 

ous, and (iv.) Artificial. The condition, he says, essential to the production 
of all these kinds, and the only one, is paralysis or inertia, or complete in- 
action. Such is the condition of the whole organ at the time of production 
of the first two kinds : in the last two kinds the accident is accom- 
panied by uterine activity, but, as these cannot exist in the same part, the 
paralysis is partial, and the activity is partial. He afiirms that activity 
of the whole of the uterus, or of its body, renders inversion impossible. 

Force may be applied from above to push the paralysed wall into the 
uterine cavity ; or from below to pull it into the cavity. In the spon- 
taneous kinds it is to be found in the mechanical conditions of the 
abdomen, in the ordinary down-bearing effort, or in the absence of the 
retentive power of the cavity however produced. In connection with 
the artificial kinds I may refer to cases where the cause is to be found 
in pulling upon the cord — " manoeuvring with the placenta," as Mat- 
thews Duncan aptly terms it. No doubt when the attachment of the 
placenta is to the fundus, the disposition to inversion is aggravated by 
traction. 

On the whole, it may be considered that traction of the cord as a cause 
of this accident is overrated, especially in modern times when better 
knowledge commands more accurate management of the third stage of 
labour. Shortness of the cord, whether in length or from coiling, has not 
the importance formerly attributed as a cause; unless indeed the labour 
be precipitate or the patient rapidly delivered in the upright position. 

Spontaneous active inversion is probably the most common kind: 
paralysis of a portion of the fundus or placental portion leads to the 
depression; the paralysed projecting part is further seized, pushed 
down, and expelled by the contracting parts through the os uteri or 
into the vagina. 

That inversion may begin at the cervix has been clearly demonstrated 
by Dr. Taylor of New York in a case of his own ; in that of E-eeve and 
others the condition began by eversion of the os, and rolling of the body 
and fundus out of the cervix. 

Dr. Duncan admits that, under powerful contraction of the fundus 
and relaxation below that part, inversion of the lower part of the cervix 
may occur alone ; and he says that it is not rarely observed after delivery. 
He depicts diagrammatically the extent to which the change may go in 
the direction of inversion ; but does not say that he has seen it occur 
in the complete degree observed by Dr. Taylor. That spontaneous 
inversion of the nulliparous uterus can take place has been strongly 
denied. The case recorded by Dr. Taylor is a clear instance in the 
proof of its occurrence ; other instances recorded by careful and com- 
petent observers render it indisputable that such an event may happen. 

Etiology. — In the first place the changes coincident with pregnancy 
and parturition undoubtedly have the largest share in disposing to this 
accident. By far the greater number of cases occur in primiparae. In 
Crampton's collection of cases 88 out of 176 were after first labours. It 
rarely happens in conjunction with abortion or miscarriage. 



CHRONIC INVERSION OF THE UTERUS 915 

Conditions in some respects analogous to pregnancy also act, though 
much more rarely, as disposing causes. 

Distension of the cavity and relaxation of the walls of the uterus are 
important factors in the event. Deficiency in muscular tone and irregular 
or imperfect contraction tend to favour its production. 

In women of feeble and lymphatic constitution, more particularly after 
severe haemorrhage when the uterus is limp and flaccid, the liability is 
greater. Some individual peculiarity is also exhibited in those women 
in whom inversion has taken place in successive confinements. 

Inversion occurs after abortion, in rare cases ; generally as the result 
of some applied force or accident. 

In the presence of morbid growths affecting the structure of the uterus 
there is, as a rule, dilatation of the interior. This is likewise to be noted 
in the case of tumours growing inwards, more so when attached to the 
fundus. Of the 400 cases given by Crosse 50 are noted as connected 
with tumours. Pediculated fibroids are the most common ; with these 
it may occur spontaneously ; or again, after removal of an intra-uterine 
tumour with a broad attachment. Some alteration in the walls of the 
uterus at the site of the growth, contractions at the menstrual periods, 
and intra-abdominal pressure are the usual associations which cause the 
body to be projected through the cervix. In sarcoma this is more fre- 
quent : Dr. A. R. Simpson met with it in 4 cases out of 48. It rarely 
occurs with epithelial carcinoma. Dr. Barnes mentions two cases. 
Distension by fluids or retained secretions is more uniform and gradual ; 
in the absence of any weakened spot or external force the tendency of 
the walls to give way is less localised. 

Symptoms. — When this event occurs suddenly and completely in its 
puerperal form the symptoms are those of profound shock and collapse, 
accompanied by intense pain and haemorrhage. The pain is fixed and 
persistent ; the bleeding continuous and profuse. The absence of the 
uterus from its normal position will remove all doubt as to the nature 
of the accident. 

In the partial form the symptoms are not so characteristic ; indeed, 
unless a thorough examination be made at the time, the accident may 
escape observation. 

In chronic inversion the symptoms are anaemia and impaired health; 
irregular haemorrhages, often profuse ; discharges ; sometimes urinary 
troubles ; local pain and discomfort ; difficulty in walking. In this 
way women have been known to drag on a miserable existence for many 
years, and die ultimately of exhaustion, peritonitis, or septicaemia. In 
some instances, however, patients have reached advanced age without 
any discomfort and even without knowledge of their ailment ; and others 
have suffered little more than inconvenience from the displacement. 
Such immunity has generally been in women who have passed the 
climacteric period. 

Diagnosis. — In a simple case the diagnosis is easy. In complex 
cases definite dia.srnosis is sometimes attended Avith difficulties which even 



9i6 SYSTEM OF GYNECOLOGY 

accomplislied experts have not been able to overcome. The history of 
the case should be carefully inquired into ; it is suggestive, and of con- 
sequence in sifting the puerperal from the non-puerperal origin. 

On examination a smooth pyriform or round tumour is felt in the 
vagina, or protruding through the cervix ; it bleeds readily when handled. 
The cervical ring is often high up, and the fold of the cervix can be 
felt all round ; if traction by a fillet or noose around the body be possi- 
ble the fold can be made to disappear — a fact of some importance in 
differential diagnosis from polypus. The depth of the cervical depres- 
sion depends upon the extent of the inversion, but the continuity can 
be traced round the base without any sign of an opening. 

In the dorsal position, with two fingers in the rectum and the opposing 
hand placed over the hypogastrium, the body of the uterus is noted to 
be absent from the normal position, and the fingers of the hands can be 
made to meet. The two forefingers of opposite hands in the vagina and 
rectum respectively may also be made to approach each other over the 
inversion. The recognition of the peritoneal orifice of the inversion is 
of much importance when it can be felt through the rectum or through 
the abdominal wall. 

A sound passed into the bladder, with the concavity turned back- 
wards, can readily be met by a finger in the rectum above the inverted 
uterus. If the inversion can be brought to view by a speculum, or by 
sufficient traction, the colour may be seen, and possibly the openings of 
the Fallopian tubes made out. 

The sensibility of the inverted uterus to puncture or pressure is not 
always a trustworthy sign ; nor is its absence by any means pathogno- 
monic. As pointed out by Newnham, on the one hand, the sensibility 
of the uterus may be diminished in the chronic stage of inversion ; and 
on the other it may be increased in polypus by inflammatory action. 
Again, if a polypus be covered by a layer of uterine tissue the distinc- 
tion, whether with regard to colour or sensibility, is less appreciable. 

Differential Diagnosis. — When a polypoid tumour is present in the 
vagina its attachment can generally be reached, and a sound can be 
passed through the cervical opening into the uterus for some inches. 
Adhesion round the base rarely precludes this use of the sound. Bimanu- 
ally, or by recto-abdominal touch, the body of the uterus can be defined 
in its usual position, or sometimes retroverted. It is between partial and 
chronic inversion and polypus that great difficulty in forming accurate 
conclusions is sometimes found. Velpeau, quoted by Simpson, says 
that there are cases in which doubt is the only rational opinion. 

Numbers of cases are recorded, in the practice of experienced men, 
in which the inverted uterus, or one horn of the inverted uterus, has 
been operated upon by ligature or otherwise, for supposed polypus ; 
and, conversely, in which polypoid tumours have been removed under 
the impression that the operator was dealing with an inverted uterus. 
With the progress of scientific knowledge and improved methods of 
exploration such mistakes ought to be few and far between. 



CHRONIC INVERSION OF THE UTERUS 917 

The past history of the case, as I have said, is significant. In a 
case of polypus the distance the uterine sound can be made to pass is 
a trustworthy criterion. 

The presence of the uterus in its normal position, and the absence of 
any trace of depression on bimanual examination, are the most valuable 
signs. If the tumour be sufficiently low for traction to be made upon it, 
the remnant of the cervical canal can be made to disappear in inversion ; 
while in polypus the whole uterus with the attached tumour can be made 
to descend by the same means. The coexistence of the two conditions 

— polypus with partial inversion at the site of attachment to the uterus 

— presents still more treacherous ground for differential diagnosis. 
Here we must rely mainly upon the onset and progress of the symptoms, 
together with a thorough bimanual investigation. 

The use of the uterine sound renders no aid in this instance ; but 
possibly the depression or dimpling of the uterus may be felt by the 
combined use of the hands. 

It would be justifiable in such cases to dilate the uterus and, under 
an anaesthetic, to examine the internal and external surfaces more ex- 
actly. The risk of such a proceeding would be warranted in the face of 
a greater evil, that of operative interference without precise knowledge 
of the actual conditions. 

From prolapse of the uterus the diagnosis should be easily effected. 
The procident mass is wider above than below ; at the lower end the 
orifice of the os uteri can be seen, and a sound passed into it. These 
facts will suffice for the purpose. Moreover, the sound passed through 
the urethra goes downward in prolapse, upward in inversion. Manipula- 
tion detects the body of the uterus and the elongated cervix, which in 
prolapse are readily movable ; while examination by the rectum and 
recto-abdominally shows clearly the relative position of the parts. In 
old standing cases inversion is often attended with some degree of 
prolapse ; when the descent is marked the vagina is involved and may be 
inverted also. In this event bladder troubles are considerably increased. 

Course and Results. — In some rare instances there has laeen tolera- 
tion of the malady for many years, after involution has taken place ; 
and more particularly when the menopause has been passed. 

Occasionally, as before stated, inversion has been present without the 
knowledge of the patient, though as a rule there is continuous suffering. 
In some very uncommon instances spontaneous reinversion takes place. 
Dr. Thomas collected twelve cases; another is reported by Kemarski; 
an additional one happened, under the care of Schultze, after the removal 
of a myoma from the fundus. In this case the reinversion began at the 
cervix and was fully effected in about ten days. 

The usual course is one of discomfort, irregular haemorrhage, septic 
symptoms, attacks of pelvic inflammation, and exhaustion and wasting 
of general strength, until reduction brings relief, or death supervenes. 
The general mortality is estimated by Crampton at 20 per cent. Thus 
32 out of 120 recent cases died. Of 104 chronic cases 7 died. 



9i8 SYSTEM OF GYNECOLOGY 

Dr. Busey attributes a share of the mortality to incompetence 
and errors. He lays stress upon the disastrous results which have 
arisen from mistakes in diagnosis and treatment, and denounces the 
inexcusable blunders which have occurred even in cases under the care 
of the most renowned physicians in the profession. 

However deplorable this may be, it must be remembered that advance 
in surgical art is largely experimental. The faults of one generation are 
the foundation of success in those which follow. There is no finality 
in knowledge ; no monopoly in intelligence. The great surgeon Lisfranc, 
in speaking of this subject, observed that '^when the polypus or inversion 
has only partially opened the os uteri we are assured that the diagnosis 
is impossible — authors do not even consider the case." From this 
aspect, surely, progress has been made, and though infallibility has not 
been reached knowledge has been gained. Light has shone through 
darkness. Humanum est errare. 

Treatment. — The difficulties of reduction in chronic inversion of the 
uterus are exemplified by the infinite variety of methods employed or 
recommended by various authors. Their name is legion, for they are 
many. It must be granted that there is no one plan universally 
applicable. Every case must be treated upon its individual merits. 
Unsuccessful attempts by one method may be rewarded by success in 
another, or by a combination of methods. 

The chief obstacles to reduction are the rigidity of the cervical ring, 
with, in recent cases, increase in the volume of the uterus ; or in long- 
standing cases diminished size with firmness of the organ. Another 
difficulty is found in the mobility of the uterus and in the difficulty of 
obtaining adequate counter pressure to the force applied from below. 

Peritoneal adhesions are not frequently met with ; they are more 
often surmised than found. Experience shows that even when desired 
for the closing of the inner opening they are hard to produce artificially. 

In the commonest form of inversion, as pointed out by Schultze, 
there are two rings of the uterine wall one within the other. If the 
reduction is begun by seeking first to press the fundus upward by 
indentation a third ring is produced, which obviously increases the 
difficulty, unless the cervical constriction be already dilated or dilatable. 
The proper method is to grasp the inverted body and to press it upwards, 
so that the cervix may be dilated, and be the first part to be reduced : 
thus we imitate the method by which spontaneous rein version takes place. 

Ingenuity has been shown in mechanical contrivances, skill and 
dexterity in shrewd adaptations, and exemplary patience in manual 
efforts. The records of many isolated cases have contained the germs of 
explanation and suggestive reasoning. Erom the special to the general 
the deduction is conclusive that steady, sustained, and elastic pressure is 
the treatment likely to be attended with the greatest amount of success 
and good ultimate results. There is apparently no limit to the time 
when it may be employed with benefit ; in cases of many years' duration 
it is still applicable. 



CHRONIC INVERSION OF THE UTERUS 919 

The principle of sustained pressure may be obtained by different 
means, the main object being to dilate the cervical ring and to restore 
first that part last inverted. Sustained pressure may be solid or elastic ; 
with the hands, with instruments, or by a combination of elastic bands 
with appropriate instruments. 

The treatment may be classified as follows : — 

(i.) Reposition by hands : (a) Aided by incision (cervical, uterine, 
abdominal). (&) Aided by instruments, (ii.) Elastic sustained pressure: 
(iii.) Amputation ; vaginal hysterectomy. 

Preliminary Treatment. — In all cases some preparatory treatment is 
desirable. The patient for some days beforehand should be kept in bed, 
the diet regulated, and the bowels well moved. Free vaginal injections 
of hot water, followed by a lotion of mercuric perchloride (1 in 2000) 
should be used night and morning; the manipulating hands must be 
thoroughly cleansed. 

In attempting manual reposition the patient should be placed in the 
lithotomy position at the edge of a level table. A Clover's crutch is 
used, and an anaesthetic must always be administered. The use of a 
Barnes' bag in the vagina for some days beforehand may make more 
room ; and in some instances may even of itself effect reposition (Kroner). 
Gariel's air pessary has also been used with the same result. 

Emmet's method is as follows : The hand is placed in the vagina, 
the fingers and thumb encircling the portion of the body close to the seat 
of inversion, the fundus resting in the palm of the hand. This portion of 
the body is firmly grasped and pushed upwards, and the fingers are then 
immediately separated to the utmost. At the same time the other hand 
is employed over the abdomen in the attempt to roll out the parts form- 
ing the ring, by sliding the abdominal parietes over its edge. As the 
transverse diameter of the cervix and os is increased by the outspread 
fingers the long diameter of the body becomes shortened. In one of 
Emmet's cases reduction was completed in three hours and fifty-five 
minutes. In another, after three hours' effort, the treatment was stopped 
for the time, and resumed a month later. Five hours, with change of 
operators, was spent on this occasion without success ; but finally, a week 
after the latter attempt, the inverted uterus was completely reduced in 
twenty-seven minutes by the same method. 

To aid fixation the uterus was drawn down to the vulva, and the 
edge of the cervix on each side seized with tenaculums, which frequently 
tore out. Aran recommended Museux's forceps or tenaculum hooks for 
this purpose; and Ereund introduces broad silk ligatures at several 
points of the circumference, and thus forcibly drags down the vaginal 
portion while pressing the body upwards. 

]^oeggerath compresses the body of the uterus, opposite to each 
horn, by the thumb and finger ; so as to indent it on one side or the 
other. When this can be effected the indented horn acts as a wedge 
which facilitates the passage of the remaining portion of the body. 
Marion Sims succeeded readily in pushing in this part of the uterine 



920 SYSTEM OF GYNECOLOGY 



wall after the body had entered the cervical ring — a method previously 
advocated by Kiwisch. It is stated by Dr. Thomas to be more applicable 
and possible at this stage of the process than at the beginning of the 
treatment. 

Courty insists upon the necessity of keeping the cervix fixed with two 
fingers introduced into the rectum. The cervix is drawn down outside 
the vulva and held with Museux's forceps : the index and middle fingers 
of the left hand are introduced into the rectum, and by bending them 
forward the cervix is easily fixed through the rectal wall. With the 
right hand the uterus is pushed back into the vagina ; the fundus, con- 
tained in the palm of the hand, being turned towards the pubes. With 
the thumb and index finger of the right hand pressure is exercised on the 
pedicle of the tumour, so as gradually to increase the depth of the utero- 
cervical groove. The first stage is accomplished by pushing the body 
of the uteras upwards as stated, while the neck is retained through the 
rectum ; the second by compressing the fundus laterally, and by pressing 
the thumb into a horn of the uterus. 

Tate's method is ingenious ; it consists in fixing and dilating the neck 
by inserting two fingers of the right hand into the rectum, and the 
index finger of the left hand through the urethra, while pressure is made 
against both horns by the thumbs. 

Many other plans have been proposed ; some original, some based 
upon combination of known methods. 

Watts of New York easily effected reduction in a case by the 
following plan : " The uterus is drawn down to the vaginal outlet, two 
fingers are placed in the rectum, one of these through the wall into the 
depression : the uterus is then pushed on to it from the vagina, the 
second finger is then added to the first, and when sufiicient dilatation 
of the ring is ensured the uterus can be returned." 

Barrier (9a) made pressure with both hands, pressing the thumb 
against the fundus, and the cervix against the sacrum for counter 
pressure. 

Incision. — Sir James Simpson (73a) found that in forcible reposition 
the edges of the cervix were fissured or slit ; he therefore suggested 
incision as an aid. Marion Sims also proposed the same method. 

Dr. Barnes (op. cit. p. 741), writing in 1869, states that for twenty years 
he had taught in his lectures that the unyielding cervix may be divided 
by incisions carried into its substance from above downwards, at different 
points of its circumference ; pressure then applied will cause it to yield 
easily. In one case this was accomplished successfully. The uterus was 
drawn down by a sling noose of tape, and three incisions were made, one 
on each side and one posteriorly. Still he recommends the use of this 
only after a trial of Tyler Smith's plan, and then with great caution. 
Sabseqnently he advises that two incisions only should be made, and 
that rein version should be limited to elastic pressure. 

Dr. Matthews Duncan treated one case by incision from the internal 
OS to the middle of the body in front and behind, followed by application 



CHRONIC INVERSION OF THE UTERUS 921 

of taxis for reduction — a plan fraught with considerable risk from haemor- 
rhage and septic infection. 

Other cutting operations have also been proposed in conjunction with 
internal dilatation. Browne describes this method as follows : The 
inverted fundus is drawn outside by strong volsella forceps until the 
openings of the Fallopian tubes are seen. An incision an inch and a half 
long is then made posteriorly ; through this a dilator is passed up into the 
cervix, and expanded until the tissues are felt to relax. The opening is 
then further stretched by hard rubber dilators ; the incision is sutured, 
and the inversion reduced by manipulation. With the incision, stretch- 
ing, and handling, it would seem that the patient is exposed to risks 
which make the operation hazardous, and hardly justifiable with the 
alternative of others which have stood the test of experience. 

Somewhat similar is the practice of Kllstner, which he thus describes 
in one case: Patient set. 19, primip. Four different replacement meth- 
ods and colpeurysis had been tried without success. In the dorso-gluteal 
position the part was drawn with volsella forceps firmly downwards, 
so that the inverted uterus lay in the vulva ; Douglas' pouch was opened 
Avide, and the index finger of the left hand was inserted into the inversion 
infundibulum. As the latter was free from adhesions, it was possible 
to get quite to the bottom of it and to bring the whole uterus easily in 
front of the vulva. Further reversion attempts were carried out so 
that through Douglas' pouch with the index and middle fingers of the 
left hand the inversion infundibulum could be fixed, and with the thumb 
of the same hand Kiistner tried to invaginate the fundus uteri, but with- 
out success. Leaving the index finger of the left hand in the infun- 
dibulum, he cut longitudinally for a length of 2 cm. from the surface of 
the mucous membrane through the posterior wall of the uterus, exactly 
in the median line in the region of the inner os uteri. Then the rever- 
sion method previously employed was repeated, and success easily fol- 
lowed. The reverted uterus was firmly retroflexed ; a longitudinal wound 
in the posterior wall of the uterus was drawn with a volsella forceps 
into the wouud of Douglas' pouch, and the former sutured peritoneally 
by three deep and two superficial sutures ; thereupon the wound in 
Douglas' pouch was also attached with five sutures to the posterior vagi- 
nal wall with the result of recovery without febrile reaction. 

Incision through the Abdomen. — In 1869 Dr. Gaillard Thomas re- 
ported a case in which he carried out a novel plan and achieved a great 
success. The patient, twenty-three years old, had borne one child twenty- 
one months before. Fourteen determined and prolonged attempts by 
experienced and able men had failed to reduce the inversion. On the 
last of these attempts Dr. Thomas incised the site of the stricture, when 
a nearly fatal hsemorrhage followed. A week later the abdomen was 
opened in the median line, and the internal ring was dilated by specially 
made forceps. A rent was made in the anterior vaginal wall by the force 
used from below. The operation under ether lasted one hour, the actual 
replacement occupying twenty-seven minutes. The patient made a good 



922 SYSTEM OF GYNECOLOGY 

recovery. In a similar case under his care the replacement was easily 
effected, but the patient died from peritonitis forty-eight hours after- 
wards. This plan has been tried by others with indifferent success. 
The principle, however, is a rational one ; and it is offered as a substitute 
for amputation of the uterus after all other means have been fairly tried. 
As such it must be regarded as a valuable contribution to the methods 
of treatment at our disposal ; it is certainly not more difficult, and it is 
less dangerous than amputation. 

In 1885 I published a case in which reduction was attempted on 
somewhat similar lines. After renewed efforts by taxis and pressure 
the abdomen was opened and the constricted ring dilated by bone glove 
stretchers. A thread of whipcord was then passed from above through 
the fundus, and a button was attached to the distal end. Continued 
upward traction for nearly an hour failed to make any impression towards 
replacement. Two weeks later the condition of the uterus induced me 
to remove it through the vagina by elastic ligature. The patient made 
a rapid recovery. 

The Hand and Instruments. — Dr. Thomas used as a substitute for 
the hand a conical plug of box-wood four inches long for making counter 
pressure over the abdomen. The cone was inserted into the abdominal 
ring of the uterus, and it was gradually forced down into the inverted 
fundus for such a distance as to dilate the cervix and allow reposition. 
A rectal bougie has been used for the same purpose, or a cone eight 
inches long and one inch diameter, or forceps wrapped with gauze. 

Elastic sustained Pressure. — Sustained pressure has been obtained 
in a variety of ways. Dr. Tyler Smith in 1858 made an important ad- 
vance upon the former methods of treatment by the use of elastic press- 
ure. He succeeded by placing a Gariel's air pessary into the vagina, 
upon which external pressure was exercised by a T-bandage and a gradu- 
ated compress placed at the vulva. By this means slow and gradual 
dilatation of the os is produced, with softening of the cervical ring ; and 
opportunity is thus given for the inverted uterus to recover itself, or 
assistance may be given by the hand. Dr. Thomas modified this plan by 
packing round the inverted uterus with tampons of carbolised cotton 
soaked in glycerine ; then he introduced an india-rubber bag filled with 
water, and retained it in position by a broad strip of plaster passing be- 
tween the thighs from the lumbar region behind to the umbilicus in front. 
Pressure is regulated by injecting more water, or letting some out by 
means of a stop-cock. As already noted, the same principle has been 
adopted in a more manageable form by the use of Barnes' bags filled 
with air. "A bag consisting of a double-walled india-rubber capsule 
which is slipped over the uterus has been devised by Thiry. When 
distended with air it presses and pushes up the inverted fundus." 

Dr. White of Buffalo was one of the earliest surgeons to direct atten- 
tion to the benefit of sustained pressure. In his plan pressure is made by 
a spiral spring, one end of which is placed against the breast of the operator. 
The spring is prolonged into a curved stem of wood or rubber, at the end 



CHRONIC INVERSION OF THE UTERUS 



923 



of which is a disc tipped with soft rubber. One hand is introduced into 
the vagina to grasp the uterus and keep the cup in position, while the free 
hand is employed over the pubes to make counter pressure, and assist in 
expanding the inner depression of the inversion. The spring requires a 
pressure of eight to ten pounds to bring it down. With the patient in 
the dorsal position at the end of the table, and under an anaesthetic, 
this method is capable of producing effective results, tedious and weari- 
some though it be. 

Elastic Pressure. — This is by far the most efficient method yet known. 
The cardinal points are that it should be gentle, elastic, and sustained in 




Fig. 242. 



the direction of the pelvic axes. It must be repeated again and again, if 
necessary, and kept up persistently and perseveringly with vigilant care. 
With this method in view previous prolonged handling, squeezing, 
and pressure by taxis, is unwarrantable. It is wiser and safer to begin 
with it at once after preliminary antiseptic irrigation. Aveling's repositor 
is the best means of producing the pressure. This consists of a stem 
with a double curve — perineal and pelvic — surmounted by a cup which is 
placed against the fundus. The pressure is exerted by four elastic rings 
fastened by bands to a waist belt, which in its turn is supported by 
shoulder-straps. By the adaptation of these the degree and the direction 
of the pressure can be very fairly regulated. Cups of different size are 



924 SYSTEM OF GYNECOLOGY 

made to fit the stem. When the inversion is reduced the cup is some- 
times retained within the uterus, and is not easily extracted. In one 
case I had considerable difficulty in getting it out. 

In a case happening under Scanzoni's (69) notice the button end of a 
stem was retained under similar circumstances. The advice he gave 
might be followed ; that as the stem had entered by firm and persistent 
pressure it should be removed by the same means. An elastic band was 
attached from the end of the stem to the bedpost, and it was thus gradu- 
ally withdrawn. 

Dr. Galabin obviates this danger by making the cup form the 
summit of a cylinder 1| inches long. Thus the cervix is prevented from 
closing up after reduction, when the instrument is readily removed. 
Careful watching is necessary when the instrument is in place ; the bands 
may require tightening at intervals, and, if there be much pain, opiates 
must be given. Restoration is generally effected by this plan within 
forty hours. In my own case three days elapsed before the reduction was 
complete, but it was necessary to suspend it for some hours on account 
of the pain produced. Aveling states that a pressure of 21- pounds is 
sufficient to effect reduction. He reports eleven cases successfully treated 
by this method, and goes so far as to say that every case of inversion can 
be cured by reposition. However, he subsequently recorded one where 
it did not succeed. 

When known methods have failed after repeated attempts, or where 
firm adhesions exist, the inversion may become irreducible. Under these 
circumstances Emmet proposes, " where the fundus can be gotten 
within the cervix," to bring the edges of the cervix together by silver 
sutures for a time, until additional efforts at reduction can be made. 
Failing this he denudes the edges of the cervix, and unites them per- 
manently, leaving a small space open at each end. 

He regards this plan as far preferable to abdominal incision or to 
amputation. Indeed, he looks upon the mortality of amputation as so 
great that he would not resort to the operation under any circumstances. 

Amputation. — The mortality of this operation is as high as 30 per 
cent. It should only be practised as a last resort. Indeed, in the light 
of present knowledge the instances in which it is admissible must be 
excessively rare. When in the wide field of treatment the relative 
infrequency of irreducible cases is remembered, the chances of being 
urged to amputation must be very remote. The chief dangers of ampu- 
tation are haemorrhage, retraction of the stump within the peritoneal 
cavity, and septicaemia. Amputation by the knife, with certain pre- 
cautions, is the most direct method. The uterus is drawn down and a 
temporary elastic ligature placed around the neck ; three or four wire 
sutures are then passed through the cervix from before backwards, and 
the uterus amputated half an inch below these. Bleeding points are 
ligatured, and the sutures are brought firmly together over the stump. 
Superficial sutures are placed to unite the mucous membrane, and the 
elastic ligature is now removed ; or a ligature may be passed through 



CHRONIC INVERSION OF THE UTERUS 925 

the neck and tied laterally so as to control the uterine vessels, the uterus 
being removed below this. 

Vaginal hysterectomy is another method of removing the uterus. 
The broad ligaments are tied or clamped with forceps on both sides, when 
the uterus can be rapidly removed by scissors. The vaginal space is 
packed with iodoform gauze. Eigid antiseptic precautions place these 
operations on a more secure footing, and greatly enhance the prospects 
of recovery. 

The elastic ligature still finds much favour in France. It is described 
by Courty as presenting more advantages and fewer dangers than any 
other plan of extirpation. He advises that before applying it a groove 
should be made round the pedicle of the tumour by the actual cautery. 
Elastic tubing is used, and it is tightened daily until the tumour falls 
off, which is generally about the twelfth to the eighteenth day. 

The ecraseur has been used with good results in the hands of some 
surgeons, and the galvano-cautery has been successful in the practice of 
Spiegelberg. The use of both is destined to aid the progress of art 
towards more efficient and safer measures based upon sounder principles. 

Edward Malins. 



REFERENCES 

1. Abegg. "Inversio Uteri," Centralh. f. Gymik. Leipz. 1893, xvii. 473.-2. 
Arbuckle. "Complete Cure of Inversion of the Uterus," Lancet, London, 1885, ii. 
1183. — 3. AvELiNG. " On Inversion of the Uterus, with Ten Cases successfully treated 
by the Sigmoid Repositor," B. M. J, Lond. 1886, i. 475. — 4. Baldy. "Inversion of 
the Uterus," Med. and Surg. Rep. Phil. 1891, Ixv. 123. — 5. Barber. "Case of Inver- 
sion of the Uterus, with complete Prolapse," Lancet, Lond. 1887, ii. G()0. — (>. Barkas. 
"Complete Inversion of the Uterus," Australas. Med. Gaz. Sydney, 1886-7, vi. 223. — 
7. Barnes. " Inversion of Uterus," 7>o>/cef, Lond. 1886, i. 420. — 8. Barnes. "Com- 
plete Chronic Inversion of the Uterus," B. Gynsec. J. Lond. 1888-9, iv. 258. — 9. 
Barrett. "Complete Inversion of the Uterus," B. M. G. Lond. 1887, i. 508. — 9a. 
Barrier. Bulletui de I' Acad, de med. April, 1852. — 10. Battlehner. " Ueher Gebar- 
mutterumstUlpung," Verhandl. d. d. Gesellsch. f. Gyniik. Leipz. 1888, ii. 319. — 11. 
Biggs. "Inversion of the Uterus," B. M. J. Lond. 1886, i. 739. — 12. Boxall. 
"Complete Inversion of the Uterus," Mid. Hasp. Rep. 1891, Lond. 1892, 70.-13. 
Brewis. "Spoutaneous Inversion of Uterus," Edin. M. J. 1887-8, xxxiii. 128. — 14. 
Browne. " A New Operation for the Reduction of Chronic Inversion of the Uterus," 
New Y. M. J. 1893.-15. Chadwick. " Gradual Reposition of an Inverted Uterus by 
a New Contrivance," Boston M. and S. J. 1885, cxii. 289. — 16. Chambers. " A Case 
of Complete Inversion of the Uterus of 25 Months' Duration, reduced by graduated con- 
tinued Pressure in less than 4^ Hours." Australas. M. Gaz. Sydney, 1885-6, v. 66. — 
17. Crampton. "Complete Inversion of Uterus following Parturition, with Tables," 
Am. J. Ohstet. N. Y. 1885, xviii. 1009. — 18. Cullingworth. "Inversion due to large 
Polypus," Lancet, Lond. 1890, i. 1355. — 19. Dahlmann. " Zwei Falle von Inversion aer 
Gebarmutter nebst einigen Bemerkungen," Frauenarzt, 1887, ii. 119. — 20. Dandois. 
"Inversion uterine chronique, ligature elastique, gue'rison," Rev. med. Louvain, 1885, 
iv. 533.-21. Davies. "Chronic Inversion of the Uterus." B. M. J. Lond. 1885, ii. 
7.37.-22. Demons. " Un cas d'inversion uterine," Mem. et Bull. Son. de med. et chir. 
d° Bord. 1886, 59. — 23. Dodge. "Case of Inversion of the Non-puerperal Uterus," 
Am. J. Obst. N. Y. 1890, xxiii. 381.— 24. Dumenil. "Cas de reduction d'une inver- 
sion uterine par la ligature elastique," Union med. de la Seine-Inf. 1886, Rouen, 1887, 
XXV. 31.— 25. Duncan, J. M. "Clinical Lecture on Chronic Inversion of the Uterus," 
Med. Times and Gaz. London, 1884. i. 275.-26. Duncan, W. "Complete Inversion 
of Uterus of Nine Years' Duration, Reduction by Aveling's repositor; cure; remarks." 



926 SYSTEM OF GYNECOLOGY 

Lancet, Lond. 1884, ii. 590. — 27. Emmet. Principles and Practice of Gynaecology, 
p. 419, 1875. — 28. Fauoon. " Sur une forme particuliere d'inversion polypeuse de 
I'uterus (inversion supero-laterale), amputee par I'ecraseur-lineaire, avec suture," Bull. 
Acad, royale med. de Beige, Brux. 1887, iv. s. 1, 723. — 29. Fox. "A unique and 
very interesting Case of Acute Inversion," Med. Reg. Phila. 1887, i. 87. — 30. Gray. 
"Inversion of the Uterus," B. M. J. Lond. 1892, i. 1253.— 31. Harvey. "Amputa- 
tion of Inverted Uterus," Indian M. Gaz., Calcutta, 1886, xxi. 154. — 32. Hensgen. 
" Zwei weitere Falle von Inversion der Gebarmutter," Frauenarzt, Berl. 1887, ii. 373. — 
33. Herman. " Inverted Uterus," Tr. O, S. 1886, xxvi. 83. — 34. Hertoghe. "Ampu- 
tation de I'uterus inverse par la ligature elastique ; guerison," Rev. med. Louvain, 1888, 
vii. 499. — 35. Hicks. "Case of luversio Uteri; reduction; recovery." B. M. J. 
Lond. 1889, ii. 1338. — 36. Hirsh. "Inversion of Uterus," Internal Clin. Phila. 
1892, 2 s. ii. 294. — 37. Hutchinson. "Another case of complete Inversion of the 
Uterus," Lancet, Lond. 1889, i. 886. — 38. Johnson. "Two cases of Inversion of the 
Uterus, treated after Wing's method," Am. J. Ohst. N. Y. 1884, xvii. 815.-39. Kara- 
FiATH. " Uterus-inversion in Folge einer Geschwiilst ; Operation ; Heilung," Pest. med. 
Vlin. Presse, Budapest, 1883, xix. 1023. — 40. Kempe. " Case of Inversio Uteri of Four 
Months' standing; Cure," B. M. J. Lond. 1888, ii. 15.-41. Kocks. " Zur Therapie 
der chronischen totalen Uterus-inversion," CenU^alhl.f. Gyndk. Leipz. 1890, xiv. 658. — 
41a. Kroner. Arch. f. Gyn. xiv. 1879. — 42. Krukenberg. "Zur Behandlung der 
Uterus-inversionen," Centr. f. Gyniik. Leipz. 1888, x. 17.— 43. Kustner. " Methode 
Konservirender Behandlung der inverterirten Inversio Uteri puerperalis," Centr. f. 
Gyndk. Leipz. 1893, xxii. 945. — 44. Lauenstein. " Fall von Inversio Uteri," Centralhl. 
f. Gyndk. Leipz. 1883, vii. 731. — 45. Laurence. "Complete Inversion caused by a 
Fibroma in the Fundus ; spontaneous Reinversion upon Removal of Tumour." B. M. J. 
Lond. 1894, i. 1243. — 46. Lee. "Inversion of the non-parturient Uterus and its 
Treatment, with Notes of two Cases," Am. of Ohst. N. Y. 1888, xxi. 616. —47. Lefort. 
"Inversion uterine; ligature elastique; guerison." Bull, et mem. Soc. de Chir. de 
Paris, 1887, n. s. xiii. 201. — 48. Leprevost. "Inversion uterine irreductible ; am- 
putation de I'uterus par la ligature a traction elastique; gue'rison." Bull, et mdni. 
Soc. de Chir. de Paris, 1888, n. s. xiv. 503.-49. Macan. "Chronic Inversion of 
the Uterus." Med. Press and Circ. London, 1884, n. s. xxxvii. 47. — 50. M'Intosh. 
"Complete Inversion; Treatment by Abdominal Section," Med. Rec. N. Y. 1893, xliv. 
176. — 51. Malins. " Chronic Inversion of the Uterus, Abdominal Section; subsequent 
Amputation," Lancet, 1885-7, p. 401. — 52. Marcy. "Chronic Inversion; Reduction 
by a New Method," J. A^n. M. Assoc. Chicago, 1889, xiii. 86. — 53. Martin. " Chronic 
Inversion of Uterus successfully treated with Continuous Elastic Pressure," Birm. Med. 
Rev. 1894, xxxvi. 219. — 54. Meyer. " Notes on Two Cases of Invei'sion of the Uterus," 
Austral. M. J. Melbourne, 1886, viii. 165. — 55. Moullin. "Inversion of Three 
Years' Duration, Reduction successfully Accomplished," B. Gynsec. J. London, 1891-2, 
vii. 486. — 56. Munde. " Laparotomy for Reduction of an Inverted Uterus," iV. Y. M. J. 

1888, xlviii. 451. — 57. Murray. "Note of a Case of Inversion of the Uterus 
occurring immediately Post-partum and resulting in spontaneous Amputation," Tr. 
Edin. Ohst. Soc. 1882-3, viii. 42. — 58. Myers. " Chronic Inversion with Amputation," 
Tr. Am. Ass. Ohst. and Gynec. 1892, Phila. 1893, v. 194. — 59. Newman. " Inversion 
of Uterus, of Sixteen Months' standing. Replacement; Recovery," B. M. J. London, 

1889, i. 1057; Tr. Ohst. Soc. 1889, 1890, xxxi. 166.-60. Oliver. "Uterus inverted 
for nearly Twenty Years becoming Malignant," Lancet, London, 1893, ii. 28. — 61. 
Outin. " Renversement de I'uterus ; reduction; guerison sans accident," i^rcmce med. 
Paris, 1889, ii. 1110. — 62. Peraire. "Inversion uterine complete avec prolapsus 
consecutive a la deliverance ; metrorrhagies abondantes mettant la vie de la malade 
en danger; reduction de I'uterus; guerison," Anyi. de gynec. et d'ohst. Paris, 1893, 
xl. 1894. — 63. Perier. " De la ligature a tractions elastiques uterine," Rev. de chir. 
Paris, 1886, vi. 969. — 64. Pickel. "Complete Inversion and Prolapsus of Uterus," 
.N. Y. J. Gynsec. and Ohst. 1894, v. 124.-65. Reeve. " Moot Points in regard to In- 
version of the Uterus," Tr. Am. Gynec. Soc. 1884. New York, 1885, ix. 69.-66. 
Reid. "Complete Inversion of Uterus reduced by Systematic Tamponment of the 
Vagina," JV. York M. J. 1891, No. 263.-67. Remy. " Du me'canisme pathogenique 
de I'inversion uterine recente puerperale," Arch, de Tocol. et de Gynec. Paris, 1894, 
xxi. 257. — 68. Remy. "Deux cas d'inversion uterine," Arch, de Tocol. Paris, 1891, 
xviii. 81.-69. Scanzoni. Diseases of Women, p. 141.-70. Schauta. "Ein Fall 
von Inversio Uteri im 78 Lebensjahre," Arch. f. Gyndk. Berl. 1892, xliii. 30. —71. 
ScHOFiELD. " Complete Inversion in a Primipara," B. M. J. London, 1894, i. 633. — 



DISEASES OF THE FEMALE BLADDER AND URETHRA 927 

72. ScHULEiN. " Beitrag z. Lehre vou der Behandlung der Inversio Uteri," Ztschr. 
f. Gehurtsch. u. Gijndk. Stuttg. 188-i, x. 345. — 73. Shapley. "Complete Inversion 
of the Uterus," B. M. J. London, 1887, i. 329. —73a. Simpson, Sir James. JSdin. 
Med. Journ. July 1867, p. 67.-74. Sinclair. "Inversion of Uterus," B. M. J. 
Lond. 1886, i. 641. — 75. Tait. "An Instrument designed to assist in the Reduction 
of Inversion of the Uterus," B. Gynsec. J. Lond. 1888-9, iv. 309. — 75a. Tate. 
Cincinyiati Lancet and Observer, 1871. — 76. Teale. "Chronic Inversion of Uterus; 
attempted Reduction by Taxis ; Laceration of Vagina into Douglas' Pouch; Recovery," 
Ijancet. Lond. 1887, i. 11. — 77. Teuffel. "Inversio Uteri completa," Centralhl. f. 
Gynclk. Leipz. 1888, xii. 401. —78. Wallace. " Note on History of Cases of Chronic 
Inversion of Uterus after Reduction," Med. Press and Circ. Lond. 1894, 2 s. Ixiii. 
108. — 79. Waterfield. "Acute Inversion of Uterus; spontaneous Reduction; 
Recovery," Lond. 1893, i. 1109. — 79a. Watts. Ajiier. Sijst. Gyn. vol. ii. p. 715. 
80. Weissenberg. " Inversio Uteri nach Abort ; rasche und spontane Reduktion durch 
Tamponade," Frauenai^tz, Berl. 1889, vi. 8. — 81. Werth. " Ueber partielle Inversion 
des Uterus durch Geschwiilste," Arch. f. Gyndk. Berl. 1893, xxii. 65. — 82. "Chronic 
Inversion of Uterus of Twenty-one Months' Duration reduced by Colpeurysis," J. 
Am. M. Ass. Chicago, 1887, viii. 22; diso. 44. — 83. "Spontaneous Reduction of a 
chronically inverted and completely prolapsed Uterus," Boston Med. and Surg. Jour. 
1892, cxxvii. 39. — 84. " Ein Fall von totaler Inversio Uteri in Folge ; spontaner 
Geburt eines fibrosen Polypen ; Heilung, ' Memorahillen. Heilbr. 1894, n. F. iv. 217. — 
85. " Inversion totale de I'ute'rus de cause difficile a determiner," Gaz. med. de Nantes, 
1884-5, iii. 117. — 86. "Inversion uterine irre'ductible ; amputation de I'uterus par la 
ligature avec tractions elastiques; guerison," Lyon med. 1886, li. 441, Disc. 455. — 
87. "Note sur I'inversion uterine et son traitement," Arch, de med. et de chlr. prat. 
Brux. 1887-8, ii. 113. 

E. M. 



DISEASES OF THE FEMALE BLADDER AND UEETHRA 

Morbid conditions of the lower urinary organs in the female, as in the 
male, chiefly show themselves in pain and frequency in micturition. 
In a large number of these cases the manifestations depend upon the 
presence of cystitis in a more or less severe degree ; and it is a point of 
first importance to determine whether cystitis be present, or only some 
condition resembling it in its more prominent features of pain and fre- 
quency of micturition and the presence of pus and blood in the urine : 
it is important, in the next place, if it be cystitis, to determine on what 
local or remote cause it depends. 

Diseases of the Urethra. — The morbid conditions met with in 
the female urethra are but few. 

Developmental defects : these are, (i.) Entire absence of urethra ; 
(ii.) Hypospadias; (iii.) Deficiency of internal portion; (iv.) Atresia of 
the urethra (congenital). 

Displacement : this occurs chiefly as longitudinal traction by dis- 
placement upwards of the bladder ; it causes frequency of micturition. 

Neoplasms : such as papilloma and polypi of the mucous membrane ; 
they may cause some obstruction without much local tenderness ; in rare 



928 SYSTEM OF GYNECOLOGY 

instances sarcoma and carcinoma are met with, but the most common 
neoplasm is the vascular growth or urethral caruncle. The urethral caruncle 
consists of dilated capillaries in connective tissue covered with squamous 
epithelium, which form a small bright red tender and vascular tumour at 
the urethral orifice. The symptoms are pains on micturition or coitus, 
sometimes retention of urine. The most effective mode of treatment is to 
destroy the prominence with the actual cautery, care being taken to arrest 
any bleeding afterwards by plugging and pressure with a perineal band. 

Cysts and Abscesses. — Cysts containing clear mucoid fluid or pus are 
occasionally met with in the urethro- vaginal septum ; they are due to 
dilatation and inflammation of Skene's glands which are situated near 
the mouth of the urethra. Bartholin's glands (corresponding to Cowper's 
glands in the male) are sometimes the seat of inflammation, suppuration, 
or neoplasms. Enlarged acinous mucous glands are sometimes found 
near the external urethral orifice. 

Urethritis is usually associated with gonorrhcBa. The urethra is 
swollen and tender, and yields pus when pressed upon through the 
anterior vaginal wall. The most effective treatment is to give diluent 
drinks and copaiba, to use iodoform bougies locally, and counter irrita- 
tion, by painting the anterior wall of the vagina with tincture of iodine. 

Dilatation sometimes occurs as a result of coitus when the vagina is 
occluded ox over-distended. This very rare condition is to be remedied 
by burning a longitudinal furrow by the actual cautery with the aid of 
a grooved speculum. 

Tubercular disease sometimes begins in the female urethra, and when 
present frequently causes pain or incontinence of urine, hsematuria or 
pyuria. 

Diseases of the Bladder. — The congenital defects of the bladder 
are malposition, supernumerary bladders, absence, and ecstrophy. 

The bladder may be protruded in a hernial form when the linea alba 
is weak or deficient, or when the expansion of the oblique muscles of 
the abdomen is absent. 

If the whole of the front wall of the abdomen is deficient in the 
hypogastrium, and the bladder properly developed, the bladder will 
protrude at the opening. This is not the same thing as ecstrophy. 

In most of the cases of protrusion or displacement of the bladder 
the condition is not congenital .but acquired. 

Displacement. — Owing to its loose attachment to the wall of the 
pelvis the bladder in the woman is readily displaced. It is drawn up 
during labour, and by retroversion of the enlarged uterus, whether this 
be due to gestation or fibromyoma ; or it may be attached to an ovarian 
or fibroid tumour which has risen into the abdomen. In procidentia 
uteri, the commonest cause of cystocele, a part of the bladder is dis- 
placed downwards, and this may lie outside the vagina. In contraction 
of the sacro-uterine ligaments the bladder is drawn backwards and held 
partly open, so that it is never completely emptied. 



DISEASES OF THE FEMALE BLADDER AND URETHRA 929 

Great protrusions are sometimes met with in the middle line at the 
scar of a laparotomy wound, or of an abscess. Over-distension of the 
abdominal walls from any cause, followed by emaciation or the flaccid- 
ity of age, is a sequence which lends itself to hernial protrusion of the 
bladder as of other viscera. The inguinal, femoral, obturator, and ischi- 
atic foramens have all been the site of cystocele, sometimes accompanied 
by protrusion of a portion of bowel or omentum. Vaginal cystocele is 
by no means uncommon in fat and flabby multiparas. 

The protruding part of the bladder is uncovered by peritoneum ex- 
cept when accompanied or preceded by an ordinary hernia of large size, 
or when a great portion of the bladder is included in it. 

Besides the weakened condition of the abdominal walls or vagina, or 
the easy patency of one of the natural openings in the parietes, two other 
conditions are requisite for cystocele : these are a dilated bladder, frequent 
and considerable distension, and frequent straining efforts at micturition. 
As soon as the bladder has escaped at a hernial protrusion it acquires a 
more or less sacculated or hour-glass form ; and the urine, being con- 
stantly retained, at length decomposes, and ulceration, calculus forma- 
tion, or sloughing may follow. 

Cystocele has been mistaken for ordinary hernia, and for abscess. It 
varies in size with the quantity of urine retained, and may be distended 
by injecting the bladder with warm boracic fluid. In doubtful cases 
Agnew recommends puncture and an examination of the fluid withdrawn ; 
but this procedure has its dangers. 

If a cystocele become strangulated the symptoms may very closely 
simulate a strangulated hernia ; but, in addition, there will almost cer- 
tainly be other symptoms special to the bladder, such as blood in the 
urine, painful and frequent micturition, and pain specially referred to 
the hypogastrium and neck of the bladder. 

Petit says that in strangulated hernia of the bladder vomiting is 
always preceded by hiccough, whereas in hernia of the intestine vomit- 
ing precedes hiccough. 

Treatment. — The pouch of bladder should be kept empty of urine by 
voluntary micturition or the catheter, and by the application of a truss. 

A vaginal cystocele should be treated by an operation for contracting 
the anterior vaginal wall. Most of the cases which have been recorded 
as supernumerary bladders have been either sacculated bladders or bladders 
bisected by a membranous partition. In some the coats have been com- 
plete, and others were probably dilated lower extremities of the ureters. 
In some of the cases in which the bladder was divided into two, there 
was an opening of communication between them, in others not; one 
ureter opens into each division. Fantoni and Mollinetti have described 
cases of true multiple bladders ; that of the latter was a woman who had 
five bladders, five kidneys, and six ureters. Four of the ureters emptied 
each into a separate bladder ; the other two into the largest bladder. 

Prolapse of the bladder mucous membrane through the urethro-vesical 

3o 



930 SYSTEM OF GYNECOLOGY 

orifice is less uncommon in women than in men ; it should be treated by 
applying the actual cautery to the vesical orifice while the wall of the 
bladder is kept in place by a catheter. 

Only a few instances of absence of the bladder are on record. When 
it occurs the ureters open into the urethra, rectum, or vagina; or on 
the abdomen, generally in the median line. Agnew quotes a few cases 
in which individuals so affected lived to adult age, suffering little or no 
inconvenience ; others survived but a few days. 

Ectopion vesicae is characterised by a failure in development of the 
anterior wall of the bladder and of the abdominal wall in front of the 
bladder; whilst the posterior wall of the bladder projects at the hypo- 
gastrium where it is continuous with the anterior abdominal parietes. 

This malformation is more frequent in boys than in girls, in the 
proportion of eight or nine to one. 

In its causation the theory of arrest of development is generally 
accepted. The existence of epispadias, the absence or non-union of the 
symphysis pubis, and other associated malformations of the genital 
organs, are arguments in favour of this opinion. 

Morbid Anatomy. — Ectopion vesicae appears as a florid red body in 
the hypogastric, or hypogastric and pubic regions. In very young sub- 
jects it is not larger than a nut ; in adults it attains the size of an apple. 

The surface bleeds readily, and is often painful ; the lower part is 
always moister and more vascular than the upper ; and upon it there are 
two small round projections, which represent the orifices of the ureters : 
on watching these urine is seen to flow from them — not drop by drop 
but by a sort of feeble and irregular ejaculation. 

At the margin the epidermis is continued insensibly into the epithe- 
lium of the mucous membrane, and little islands of it are situated on 
the mucous surface — in fact, there is a tendency for the epithelium to 
change into epidermis. 

Around the ectopion the cutaneous surface is marked by irregular 
cicatrices Avhich are considered to be relics of the allantois. Above the 
ectopion is a median depression — due to the want of the linea alba — as 
high as the umbilicus. The umbilicus may indeed blend with the ecto- 
pion ; if not, it is generally very close to it. The umbilical vein is conse- 
quently elongated ; the urachus and umbilical arteries are proportionately 
shortened. 

In the female there is a separation of the labia majora, of the two 
sides of the clitoris, and of the labia minora. The external orifice of the 
vagina is a mere antero-posterior slit ; and in some cases the sex of the 
infant is doubtful. The vagina and uterus are sometimes bifid. The 
anus is often placed farther forward than normal. One of the most im- 
portant features is detected by pressing upon the pubic region, when a 
wide separation of the pubic bones, varying from 1\ to six inches (3 to 
12 centimetres), will be recognised. It is quite exceptional for the pubes 
to be united at the symphysis. 

By rectal examination much is learnt ; namely, the very forward pro- 



DISEASES OF THE FEMALE BLADDER AAD URETHRA 931 

jection of the sacrum, whereby the antero-posterior diameter of the pelvis 
is diminished. AVith the finger in the rectum, and the other hand on 
the hypogastrium, one feels the posterior surface of the ectopic bladder, 
and the separation of the pubes is still more distinctly perceived. 

Dissection shows the perineal muscles to be ill-developed, and the 
sphincter vesicae to be absent — at least, in one instance only does it 
seem that a sphincter of the urethro-vesical orifice has been found. In 
place of the symphysis is a fibrous band of varying thickness and 
resistance. 

Xothing but a layer of cellular tissue, and not always so much 
as this, separates the vesical mucous membrane from the peritoneal 
coat. 

The condition of the ureters is very important Following them 
from the bladder wall, they dip down into the pelvis before turning up 
towards the kidneys. They are frequently elongated and dilated. 

Symptoms. — Individuals with ectopion vesicae may be otherwise 
well formed and robust : most frequently, however, they are thin, weakly, 
and constantly suffering ; as the slightest friction from their linen in- 
flames the vesical mucous membrane. Thus they often die from 
ascending inflammation ending in suppurative pyelophlebitis. 

As a result of the constant trickling of urine they are always wet 
and in discomfort, and frequently affected with erythema, excoriations, 
erysipelas, or more deeply seated inflammation of the skin and tissues 
around. Thus they are always in danger of mischief ascending to the 
kidneys. Sexual appetite, as a rule, does not exist. In the female con- 
ception has occurred, the offspring being naturally formed ; but delivery 
is often difficult, and confinement almost always followed by prolapse 
of the uterus. Many malformations of the vagina coexist, especially in 
connection with the anus. Double inguinal hernia is very common. 
Sometimes the ileum terminates in the bladder. Prolapse of the rectum 
or uterus, club foot, harelip, anencephalus, and spina bifida have also 
been recorded. Ectopion vesicae is, happily, very rare. Xeudorfer com- 
putes its occurrence as twice in 100,000 infants : nine-tenths of the cases 
of ectopion vesicae die within a few days of birth. Ectopion is not, 
however, incompatible with long life, as instances are recorded of in- 
dividuals so affected attaining the age of 40, 50, and even 70 years. 

Treatment. — It must suffice here to name the modes of operation 
performed : — 

(i.) To establish a fistulous communication between the ureters and 
rectum; or (ii.) Between the bladder and the rectum. The mortality of 
these two methods has been 40 per cent, (iii.) The autoplastic or flaps 
method. Mortality, 14-6 per cent. This method has in several cases 
cured the coexisting inguinal hernias, (iv.) The removal by dissection, 
or the destruction by escharotics of the mucous membrane of the bladder, 
except around the orifices of the ureters. Sonneburg, after dissecting off 
the bladder mucous membrane, sutures the mucous membrane to the base 
of the epispadias, (v.) To close the bladder by suturing its two margins. 



932 SYSTEM OF GYNECOLOGY 

This method is sometimes combined with closure of the interval at the 
symphysis pubis, after the manner of Trendelenburg. 

According to Tuffier the alternatives are as follows : When the case 
is one of epispadias, with a small fissure at the symphysial area of the 
bladder, close the urethra and neck of the bladder by uniting the edges 
of these parts. So, too, if the defect of the bladder extends somewhat 
higher, the edges of the bladder should be freshened after dissecting up 
the mucous membrane without damage to the ureters. If the ectopion is 
complete and the separation of pubes considerable, divert the urine 
into the rectum. In a young and vigorous person employ Dubois and 
Dupuytren's method, which consists in suturing together the margins of 
the bladder. If the genital organs be atrophied, or the patient weakly, 
or affected by othej- malformations, suture the mucous membrane to the 
root of the urethra ; or establish a recto-vesical fistula and destroy the 
mucous membrane of the bladder. 

As regards the autoplastic methods, the simple flap is inferior to the 
methods by several flaps ; and the method whereby the flaps are super- 
posed is better than that by which they are simply joined together. 

Functional Disturbances of the Bladder. — i. Functional Dis- 
ease due to Structural Disease of the Nervous System. — (a) Tahes dorsalis. 
— (i.) On the motor side there may be paralysis without retention. 
This paralysis shows itself in a delay, varying from a minute to a 
quarter of an hour, in starting to micturate ; the flow may then stop, to 
go on again after an interval, and within an instant or two after the 
act seems to be completed, urine may be passed into the clothes, (ii.) 
Paralysis culminating in complete or partial retention, (iii.) Inter- 
mittent incontinence, which may be due to overflow of urine from the 
bladder ; or be caused by a peculiar irritability of the bladder, which 
leads to a slight discharge of urine directly the patient makes a move to 
micturate, (iv.) An urgent necessity to pass water, due to tenesmus, 
accompanied perhaps by cystalgia. 

On the sensory side are, in the " excess " direction, urethralgia, 
cystalgia, vesical colic ; in the " insufliciency " direction, anaesthesia of 
the urethro-vesical mucous membrane, and the loss of muscular sense of 
these organs. The vesical colic, analogous to the gastric colic, and preceded 
by crises of variable duration and intensity, is attended by excessive 
pain. The anaesthesia of the nrethro-vesical mucous membrane and of 
the muscular sense is manifested by the want of consciousness of the 
passage of urine or of the distension of the bladder. Such patients 
urinate in a routine manner at stated intervals, not because they have a 
sense of necessity or any desire to empty the bladder : they must watch 
in order to know whether they are passing water or not, and when they 
have finished ; some of these patients cannot micturate in the dark. 

(b) Pottos disease, and injuries to the brain and spinal cord, by interfer- 
ing with the vesico-urethral nerve centres, cause paralysis with retention, 
and the incontinence of retention or overflow. Disturbances from such 



DISEASES OF THE FEMALE BLADDER AXD URETHRA 933 

causes are very familiar. So, too, are the similar disturbances from 
serious injuries to the brain. 

(c) In general paralysis, according to Geffrier, there is retention 
from urethral spasm during the stage of excitement, and retention from 
paralysis during the period of depression. 

(d) In certain cases of insanity the retention is voluntary, the patients 
refusing to pass water just as they refuse to take food. 

(e) Inpatchy sclerosis retention due to spasms of the urethra is caused 
by the irritation of the lumbar centre for the sphincter of the bladder. 

2. Functional Disturbances of the Bladder connected with Epilepsy. — 
The principal of these is incontinence. It differs from common noc- 
turnal incontinence in its occasional occurrence, and by the patient 
awaking with a feeling of extreme weakness, exhaustion, and weight 
in the head, and with the tongue sore or bleeding. Incontinence some- 
times occurs during a fit of hysteria. 

In hysteria there is occasionally anaesthesia, with spasm of the neck of 
the bladder; there is great dilhculty in beginning to micturate, and this 
may increase to complete retention. In some hysterical subjects there is 
involuntary discharge of urine under strong emotion, due to spasm of the 
detrusor fibres of the bladder. Hysterical retention, due to paralysis of 
the bladder, is frequent; it is sometimes accompanied by hysterical hemi- 
plegia, or more often by paraplegia. If the paralysis affect both the 
detrusor and the sphincter vesicae, these patients get the incontinence of 
retention. 

3. Functional troubles connected with congenital malformations, and, 
4, those due to neighbouring organs, make what is often described as 
the irritable bladder. 

The sensory symptoms are cystalgic pains ; the motor symptoms, 
frequent spasms of the bladder and urethra, which cause frequent, but 
slow and painful micturition, urgent calls to pass water, and sometimes 
actual retention. 

The causes of the symptoms are congenital atresia urethrae, fissure 
of the anus, haemorrhoids, operations on the anus, intestinal worms; 
or uterine, ovarian, vaginal and vulvar disorders ; or operations on these 
parts. 

5. Functional Vesical Troubles due to Lesions of the Bladder. — The 
reflex irritation caused by vesical calculus, tumour, or fissure of the 
urethra in women produces vesical tenesmus analogous to rectal tenes- 
mus from anal fissure. A deep-seated but slight urethritis near the 
neck of the bladder often causes cystalgia. These causes of painful and 
irritable bladder must be recognised in order to treat them successfully. 

6. Functional Vesical Troubles caused by the Condition of the Urine. — 
The excess of limpid urine in Iwsterical women, urates in the gouty, 
and of phosphates in neurotic persons, and any urine which is extremely 
acid, are well-known causes of irritable bladder. 

7. Idiopathic functional disturbances of the bladder, such as 
cystalgia, and spasms both of the vesical muscle and the compressor 



934 



SYSTEM OF GYNECOLOGY 



urethrae, sometimes seem to occur independently of any ascertainable 
cause. True idiopathic cystalgia, Taffier writes, occurs in persons whose 
parents are the subject of nervous or rheumatic migraine and who are 
themselves neurotic. The determining causes are cold, damp, changes of 
season, constipation, voluntary retention, and irritability of the genital 
organs. 

8. Functional Vesical Troubles of Mental Origin. — The enormous 
influence of the mind over the functions of the bladder are proverbial. 
That polyuria, as well as frequency of micturition, is due to mental in- 
fluence is proved by the fact that if the mind is engaged and interested 
both cease as they do during sleep. The patients may pass water fifty 
times a day, yet sleep all through the night. A greatly increased capacity 
of bladder is proved to exist in these cases by the capacity for injections 
of warm water; and yet a catheter left in the bladder as a drain-tube 
does not remove the desire these patients have to pass water. 

Another form of functional disturbance from mental causes is urethral 
spasm, manifested either during micturition or during the introduction of 
an instrument. If it occur during micturition we have the condition so 
happily described by Sir James Paget as ^' stammering of the bladder," 
which renders the person incapable of micturating in presence of others, 
or even in a place where the flow of their urine can be heard. 

Even when there is no ascertainable lesion about the urinary organs 
to explain this troublesome condition, there are still many other causes of 
incontinence both in children and adults for which search must be made. 

Incontinence of urine assumes two very distinct and different forms 
— (i.) the incontinence of the drop-by-drop kind, the incessant, con- 
tinuous dribbling; and (ii.) incontinence in the form of intermittent 
large evacuations of urine. 

(a) The " continual " incontinence consisting in incessant dribbling 
of urine is due to paralysis of the vesical and urethral (the membranous 
urethra) sphincters. It may or may not be associated with retention. If 
it is, the incontinence is merely the overflow of the bladder and is the 
'' incontinence of retention." If it is '^ incontinence without retention," 
the bladder is no longer serving as a reservoir, but has become merely a 
part of a conduit placed between ureters and urethra. This is a state 
of absolute incontinence. " Continual " incontinence, if it has not been 
caused by over-distension and its effects on bladder and sphincter, is 
probably always hysterical. 

(&) Some children have nocturnal incontinence whose urinary functions 
during the day are quite normal in every respect. These are the subjects 
of incontinence of a psychopathic (mental) origin, and they constitute the 
majority of cases. It is intermittent incontinence of large quantities 
of urine : it arises from the child having a besetting dream of passing 
water, and it is aggravated by the fear that she will wet her bed. This 
form of incontinence always ceases at puberty if not before, when a dif- 
ferent turn is given to the thoughts and dreams of these incontinents. 



DISEASES OF THE FEMALE BLADDER AND URETHRA .935 

(c) In another class of cases there is incontinence of the intermittent 
form occurring at night only ; but during the day these children have 
frequent and pressing calls to pass urine, and must give immediate relief 
to their bladders, otherwise they wet their clothes. This form is due to 
irritation either of the spinal cord, of the intestines, or of the genito- 
urinary apparatus. Contracted meatus, oxaluria and lithaemia, and 
intestinal worms play an important part in it. 

{d) In another class of cases the children have both diurnal and 
nocturnal incontinence. They never think for an instant of trying to 
prevent it. They pass water in the daytime with the same unconscious- 
ness as prevails at night. This form is due either to defective contractile 
power in the urethral sphincter, or to urethral insensibility. In adults 
this may occur in consequence of hysteria, of overstretching of the 
sphincter by too large an instrument, or by digital examination. It also 
occurs as a consequence of spinal lesions, especially tabes dorsalis. 

(e) During epileptic seizures incontinence takes place at the end of the 
attack, whether it occur by night or day. It is succeeded by a feeling of 
extreme prostration and evidence of the tongue or cheek havingbeen bitten. 

All forms, except the epileptic, have a tendency to disappear at 
puberty. After twenty-live years of age they are quite exceptional, if 
not altogether unknown. Spontaneous cure sometimes unexpectedly 
follows an attack of fever or some other illness. In some cases, after 
the incontinence ceases, these persons are obliged to pass water once or 
twice during the night ; and this necessity may continue even throughout 
life. Many of them, however, get cured of their incontinence, only to 
become the prey of some other nervous affection such as spasm of the 
bladder, or irritable bladder, or to become confirmed hypochondriacs. 

Treatment. — In the psychopathic form moral treatment is the only 
useful one. The little patient must not be scolded, or punished, or 
reproached, or made a laughing-stock. She should be encouraged, 
reassured, and even told not to mind the accident. Let her not go to 
sleep with a final instruction that she must not wet herself, whereby her 
last thought is made a connecting-link with her habitual dream. On the 
contrary, coax her, if possible, into the hope that she is cured ; and assure 
her she ought not to be troubled if she should find she is not. Much is 
gained if a few nights pass without an accident, and this is sometimes 
obtained by waking the child just before the hour at which the nurse has 
ascertained that micturition takes place. Means are sometimes recom- 
mended to lighten sleep and increase the irritability of the neck of the 
bladder. A hard bed, a little tea or coffee taken late before going to 
bed, are calculated to obtain the one aim, and the passage of catheters 
or sounds will sometimes accomplish the other. [For treatment by elec- 
tricity, vide System of Med. vol. i. p. 372.] 

For incontinence due to irritable bladder the treatment consists in 
the removal of the cause ; thus vermifuge remedies and improvement in 
dietary to correct oxyluria or lithiasis, are among the means which will 
be employed. 



936 SYSTEM OF GYNECOLOGY 

Incontinence from atony, or from paralysis, will be often rapidly 
cured by electrolysis applied to the hypogastrium, or even within the 
cavity of the bladder. 

Cystitis. — I. Acute cystitis in the female, though less frequent than 
in the male, is nevertheless far from rare. The absence of the prostate 
and of the retaining influence of the male urethra, are largely accountable 
for this. Other causes, such as gonorrhoea, tuberculosis, calculus, and 
neoplasms, are common to both sexes ; while the proximity of the uterus 
and the tendency of the bladder to sympathise with its diseases and dis- 
placements add a new set of causes in the female. 

The physiological solidarity which subsists between the two organs is 
due not only to the close relationship, but to the remarkably free vascular 
communications which exist between them. In certain cases, therefore, 
the bladder is subject not only to compression but to hyperaemia by 
extension due to this vascular connection. In addition to the fact that 
the main vesical and the main uterine arteries arise from the hypogastric 
trunk there is a free, direct distribution of smaller arterioles from the 
anterior aspect of the uterus, and the vesical and anterior uterine veins 
actually unite. Observation shows that there is some increased frequency 
of micturition, associated in some cases with a slight amount of dysuria, 
just before and after the occurrence of the catamenia: this is more 
marked in multiparas and in cases of subinvolution of the uterus. 

It is found also that cases of chronic cystitis commonly exhibit exacerba- 
tions at these periods (West, Laugier, Bernardet) ; and a similar increase 
is noticed with suppression of menses or at the menopause (Civiale). 

During gestation there is an increased vascularity of the neighbouring 
parts, which is readily observed in the vagina and vulva, and depends on 
increase in the size and number of the veins and arteries, as well as on 
dilatation of capillaries ; thus is produced the so-called vaginal pulse, 
appreciable by the finger (Oisander), which extends also to the bladder. 
Frequent micturition in the early months of pregnancy, before there 
has been any notable enlargement of the uterus, is so habitual that it is 
scarcely complained of. More than 50 per cent of women experience 
this increase in frequency, pain and slight haemorrhage, but they are 
most marked in primiparas. 

Cystitis associated with chronic inflammatory conditions of the uterus 
is most rebellious to treatment, and often disappears only with subsidence 
of the uterine disease ; in cases of urinary trouble, of which the pathology 
seems obscure, the uterus should always be carefully examined. The 
mechanical influence of pressure by the uterus or its contents leads both to 
diminished capacity and to congestion, which result in greater irritability 
of the bladder and need for emptying it. This is most marked when 
there is forcible and continuous pressure from the head of the foetus or 
dystocia, particularly if the pelvis be narrow : in prolonged labour this 
pressure, though short of producing contusion and sloughing, may lead to 
cystitis. 



DISEASES OF THE FEMALE BLADDER AND URETHRA 937 

Compression differently applied so as to lead to retention of nrine is 
a fruitful source of cystitis. Tumours, displacements of the uterus, or 
even inflammatory exudations, causing compression between tliem and 
the symphysis pubis, interfere with the escape of the urine, produce both 
congestion and distension of the bladder, and may lead to incontinence, 
rupture, or grave inflammation. Such cases require gradual evacuation 
of the bladder and removal of the pressure. It is here, for the most 
part, that a peculiarly intense form of cystitis occurs characterised by 
expulsion of membrane in the form of a sac moulded to the internal 
surface of the bladder. 

Cystitis in w^onian, then, is met with, particularly at the menstrual 
periods ; at the menopause ; in connection with a congested state of the 
uterus from pathological causes ; in early pregnancy, influenced by tlie 
extension of hypersemia or by retroversion and consequent retention of 
urine ; and tow^ards the end of gestation owing to malformation or mal- 
position of the foetus. Postpuerperal cystitis, w^hich is geuerally the 
most severe, may be due to direct toxic infection, to fissure of the neck 
of the bladder, or even to the use of a septic catheter. Apart from 
pregnancy cystitis may be set up by cold, excessive coitus, or voluntary 
over-distension of the bladder. 

Etiology. — The causes of acute cystitis are (a) remote and (h) im- 
mediate. The remote are either general or local. 

Certain constitutional conditions favour the occurrence of the disease : 
these are commonly stated to be rheumatism, gout, and tubercle. 

Cold, improper food, and defective hygiene are also regarded among 
the causes of a remoter kind. 

The composition of the urine sometimes disposes to cystitis ; it is in 
this manner, no doubt, that gout is a cause of it. The toxic state of the 
urine in fever patients, as well as the retention of urine which often 
affects them, induces congestion of the bladder. Cantharides, and some 
other drugs which are eliminated by the kidneys, by passing over the 
mucous membrane of the bladder, have a distinct power to cause fre- 
quency and pain in micturition. 

Immediate Causes. — These are catheterism, gonorrhoea, vaginitis, 
and other infective processes about the vulva and external urethral 
orifice. They all produce cystitis by provoking a direct microbic infec- 
tion of the vesical mucous membrane by means of the secretion and dis- 
charges conveyed to the bladder from the urethra. 

Pathology. — The first changes in cystitis are a pronounced injection 
of the blood-vessels of the mucous membrane, especially about the 
ureteral orifices and the neck of the bladder. As the inflammation 
advances the mucous membrane SAvells, takes a bright crimson colour, 
and the distinct outline of the distended arborescent vessels disappears. 
Microscopically, the epithelial cells are swollen, their nuclei are broken 
up, and the rete mucosum is infiltrated w4th leucocytes and embryonic 
cells. The muscular coat is sometimes similarly infiltrated. Abscesses, 
ulcers, and gangrene may result. 



938 SYSTEM OF GYNAECOLOGY 

The bacteriological study of cystitis goes to show that several forms 
of pyogeiietic bacteria are capable of exciting cystitis ; but the microbe 
which has been most generally met with is the bacterium coli commune. 
Others are the uro-bacillus liquefaciens and the ordinary agents of sup- 
puration ; and, very much more rarely, the bacillus griseus, the micro- 
coccus albicans amplus, and the diplococcus favus. In men and women 
it is the colon bacillus which is most frequently found, and which is, 
indeed, in men the agent of almost all cases of cystitis ; but in women 
the staphylococci, as the elements exciting puerperal and post-partum 
cystitis, are met with almost as frequently as the colon bacillus. In 
cystitis from gonorrhoea, as well as from other causes, the same bacteria 
are found ; it is quite exceptional to meet with gonococci. 

Symptoms. — These are frequent micturition — the desire being so 
imperative that the action of the bladder cannot be controlled, though 
but a small quantity of urine may be present ; considerable smarting 
followed by some pain after the bladder is emptied ; and the presence of 
pus and sometimes of blood in the urine, often only at the end of micturi- 
tion. Acute cystitis appears in two very different degrees ; one almost 
insufferable to the patient and alarming to witness, the other much less 
severe and dangerous. 

The severity and duration of the symptoms are very variable. 
Attacks occurring during pregnancy are usually very benign, while 
those following delivery are even more severe and prolonged than 
cystitis occurring in man. Apart from pregnancy inflammation of the 
bladder undergoes exacerbation at the catamenial periods. 

Besides the above functional symptoms there are GeTtsiinphysical signs 
due to the condition of the bladder. These are : (1) pain and tender- 
ness over the trigone felt on digital examination through the vagina ; 
this pain is much accentuated if at the same time pressure be made over 
the hypogastrium. (2) Intravesical tenderness. Usually in passing a 
catheter the discomfort experienced by the pressure of the beak of the 
instrument along the urethra ceases at once after its entrance into the 
bladder ; but when cystitis exists, pain is aggravated by the presence of 
the instrument within the neck of the bladder. (3) Distension of the 
bladder with an antiseptic solution. If this is attempted, intense pain, 
accompanied with uncontrollable desire to empty the bladder, follows 
the injection of a very small quantity. 

As regards the question of temperature, M. Guyon has pointed out 
that there is no fever in acute cystitis, that the most painful forms of 
the disease show no elevation of temperature whatever, and that as soon 
as a febrile temperature appears in a patient with cystitis, it is certain 
that there is some perivesical, or, much more commonly, some uretero- 
renal inflammation. 

TJie method of examination in these cases is direct exploration by the 
finger in the vagina or by the hand on the hypogastrium — or by the 
two combined. In this way the site and degree of tenderness may be 
ascertained. In certain acute cases the introduction of the finger into 



DISEASES OF THE FEMALE BLADDER AND URETHRA 939 

the vagina, or the mere pressure of the hand on the hypogastrium, pro- 
vokes extreme suffering. In less severe instances the tliickness of the 
inflamed walls may be gauged by the combined method ; or this may be 
arrived at by pressure of the finger forwards against the pubes. The 
introduction of the sound into the bladder also may demonstrate the 
exact points and degree of tenderness. 

Diagnosis. — The affection as a rule is easily diagnosed by the three 
classical symptoms : frequency of micturition ; painful micturition ; and 
pyuria. The presence of all three of them is necessary. ^STo one of 
them, taken alone, can establish a right diagnosis. 

It is not by the amount or character of the sediment, but by the 
pain and tenderness on pressure per vaginam, and the fact that the first 
and last portions of the urine contain most pus, that we diagnose the 
cystitis to be of the neck and trigone of the bladder. When the whole 
of the bladder surface is alike involved the pus is uniformly diffused 
through all the urine. 

The cause of the cystitis ought always to be ascertained, and this 
can easily be done in the case of calculus or new growth. The chief 
difficulty consists in distinguishing tubercular cystitis in its early stage 
from cystitis due to a chronic urethral discharge. The family history 
of the patient, the bacteriological tests by means of the microscope or 
bacilli culture, and the presence of tubercular deposit in other parts, 
will give the clue to the cause. 

Pericystitis will be diagnosed by the high temperature, by the tume- 
faction felt through vagina or above the symphysis pubis, which is not 
removed by using the catheter, and by the signs of deep-seated sup- 
puration. It is very rare. 

A frequent desire to micturate, apart from any fever or alteration in 
the character of the urine, may be met with in cystocele ; but this con- 
dition is readily recognised, on examination, by a bulging into the 
vagina, and by the ability to recognise the sound when introduced in 
the pouch. 

The presence of pus in the urine, which is one of the prominent 
features of cystitis, may be met with on account of vaginal discharges ; 
but the other symptoms are absent, and on closer examination the 
source of the discharge should be discovered. 

The differential diagnosis of the various forms of cystitis is a very 
much more tedious and difficult affair. A matter of the first importance 
is a methodical examination of the uterus and its appendages ; so fre- 
quently does the bladder participate in vascular disturbances of this 
organ. It is also necessary to search for any evidence of gonorrhoea 
either in the patient or, if she be married, in her husband. The recog- 
nition of pregnancy again, in association with comparatively mild mani- 
festations, is a sufficient indication of the probable cause of the malady. 
A bacteriological investigation of the purulent deposit in the urine should 
be undertaken in prolonged or severe cases with a view of discovering 
the gonococcus or the tubercle bacillus ; but the most important means 



940 SYSTEM OF GYNECOLOGY 

of ascertaining any local condition consists in the bimanual examination 
of the bladder, and in the introduction of the finger into the bladder 
through the dilated urethra. This is undoubtedly the best means of 
discovering any foreign body, new growth, or morbid condition of the 
bladder wall. 

Treatment. — The cause of the cystitis must be removed as soon as 
possible, and the treatment, in appropriate cases, should be directed 
towards the uterus where this is also affected. Cases associated with 
pregnancy are not usually severe, and the termination of gestation may 
be counted upon to end the cystitis. Baths, narcotics, and balsamic 
drugs are beneficial ; but in really severe cases there is no remedy to be 
compared with injections of a few drops of silver nitrate (1-500), repeated 
at such intervals as give the pain of its introduction time to subside. 

The most severe cases can only be relieved by dilatation (digital) of 
the urethra, or even by a vesico-vaginal section (kolpocystotomy) which 
gives the bladder complete physiological rest. 

II. Chronic Cystitis. — As a rule cystitis in woman is of the chronic 
form ; though some of the most acute cases I have witnessed have 
occurred in women after parturition. 

The cystitis attributed to rheumatism and gout, as well as tuber- 
cular cystitis, is of a slow and persistent kind. 

Morhid Anatomy. — The mucous membrane of the bladder is of a 
slate colour, ecchymosed in places, marbled purplish, blackish, or green- 
ish, and covered with an adherent layer of muco-pus. Sometimes there 
are large or small ulcers on the surface. The changes in the mucous 
membrane affect the bladder throughout, but are most marked about 
the trigone, and least so about the base of the bladder. The mucous 
membrane is softened, thickened and swollen, and sometimes small ab- 
scesses are present both in the membrane and beneath it. The epi- 
thelium is exfoliated, the basement membrane infiltrated, and the 
capillaries hypertrophied. The muscular coats are thickened. The 
different conditions presented by the mucous membrane have given 
rise to names as various. Thus are described ulcerative cystitis, gan- 
grenous cystitis, " croupous cystitis " (that is, cystitis attended with the 
production of false membranes), and the villous form of cystitis (cystite 
fungo-vasculaire). To name these varieties is to indicate the different 
aspects the mucous membrane may present. 

In the croupous cystitis the false membrane is of a yellowish colour ; 
it is composed of fibrinous material, containing in its substance leuco- 
cytes and epithelial cells, and it is sometimes encrusted with phosphates. 
This membrane, which is frequently formed in very acute cystitis and 
in the cystitis of lying-in women, may invade the ureters and the renal 
pelves. 

In other cases the false membrane is made up entirely of epithelium 
from fifty to one hundred times as thick as the normal vesical epithelium. 

In gangrenous cystitis the false membrane may be mixed with some 
of the constituent parts of the bladder membrane more or less destroyed. 



DISEASES OF THE FEMALE BLADDER AND URETHRA 941 

Symptoms. — Chronic cystitis may arise insidiously, or may be the 
sequel of acute cystitis. 

The symptoms are the same as those of acute cystitis, but in a very 
much milder degree. The three cardinal symptoms — frequency of 
micturition, painful micturition and pyuria — are present together. The 
degree of pyuria is extremely variable. The pus is always most abundant 
at the commencement and finish of micturition, which indicates that its 
chief source is the mucous membrane about the neck of tlie bladder. It 
differs much in appearance also in different cases, being sometimes 
yellowish or greenish ; sometimes tenacious, glairy, stringy, and adherent 
to the bottom of the vessel, like a gelatinous coating of greater or less 
thickness, which cleaves for some seconds to the vessel on pouring off the 
urine, and then leaves it like a solid or semi-solid mass. 

The urine of chronic cystitis is alkaline and, if not actually am- 
moniacal, has a strong offensive odour. When the mucous membrane is 
sloughing the urine has an odour characteristically offensive. 

The physical symptoms of chronic cystitis are very slight ; and the 
general good health is maintained by many patients for a long time, even 
when the quantity of muco-pus is very large. After a time, however, 
they become feeble, lose flesh, and look pale and sallow ; the skin dries, 
the tongue is furred, and the digestion becomes difficult or painful. In a 
large number of cases chronic pyelo-nephritis is gradually induced ; in 
others, an acute attack of suppuration throughout the higher urinary 
mucous track proves fatal. 

Diagnosis. — Before making a diagnosis we should inquire as to the 
three coexisting cardinal symptoms ; namely, the frequency and the pain 
of micturition, and the presence of pus or muco-pus in the urine. The 
conditions with which chronic cystitis is most likely to be confused are 
neuropathic states of the bladder, tuberculosis of the bladder, and 
pyelo-nephritis. 

In neuropathic conditions pus is generally absent, though pain and 
frequency of micturition may be present. The bladder is not over- 
sensitive to the catheter, nor to vesical injections. With even the 
smallest trace of pus we ought to exclude simple neuralgia. 

In pyelo-nephritis there is a uniform turbidity of the urine, and the 
turbidity remains even after the urine has had time to deposit; the gen- 
eral health is impaired, there are feverish attacks and, if the bladder 
is unaffected, the urine is acid. If the bladder be carefully washed 
out, the urine which flows away through the catheter immediately after 
is turbid with pus. 

Treatment. — The proper treatment of chronic cystitis consists in 
the daily irrigation of the bladder by suitable antiseptic solutions. This 
irrigation must be conducted on a careful and systematic plan ; not only 
as regards the details of antiseptic precautions, but in other respects as 
well. It is harmful to throw in too much fluid at a time, or to inject it 
with too much force. A tender, inflamed bladder is irritated, not soothed, 
by such treatment. A soft, flexible catheter of No. 8 or 9 size should 



942 SYSTEM OF GYNECOLOGY 

always be used if possible ; and the solution to be injected should be of 
the temperature of the body, and not too strongly impregnated with 
the antiseptic substance. Only two, three, or four ounces should be 
injected at a time ; and then, after being retained for a few seconds in 
the bladder by keeping the finger tip on the end of the catheter, it 
should be allowed to escape. This process should be repeated till the 
solution returns as clear, or nearly so, as when it was injected. 

The best means of injecting the solution is by a 4 or 6-ounce 
india-rubber bottle, fitted with a graduated nozzle and stop-cock such as 
are made for this purpose. Or, instead of the india-rubber bottle, a glass 
irrigator, with a long tube and nozzle at the end, can be hung above the 
patient's head. This is, perhaps, a more convenient plan when the 
washing out is done by the patient herself. 

Various solutions are employed, thus, acetate of lead (1 or 2 grains 
to 4 ounces of water) ; dilute nitric acid (2 or 3 minims to the ounce) ; 
dilute phosphoric acid (3 or 4 minims to the ounce) ; acetic acid (4 minims 
to the ounce). These are especially useful where there is a great tendency 
to phosphatic encrustation of the bladder. Sir Henry Thompson recom- 
mends biborate of soda and glycerine ; his formula is 2 ounces of glyce- 
rine, 1 ounce of biborate of soda, and 2 ounces of water ; of this mixture, 
\ an ounce is added to 4 ounces of water to form the injection. 

Mr. Nunn, as long ago as 1872, used and recommended a solution of 
quinine sulphate, in the proportion of 2 grains to 3 ounces of water in- 
creased to 1 or 2 grains to the ounce. Another drug recommended by 
Sir Henry Thompson is nitrate of silver of the strength of i to 1 grain in 
4 ounces, increased to | grain to the ounce. Salicylic acid {^-^ per cent) is 
recommended by Bryan of St. Louis for cleansing the bladder of tenacious 
muco-pus. Creolin in \ per cent solution, resorcin, -f-^ per cent, and a 
weak solution of boroglyceride are among the numerous substances which 
may be tried. Instillations, in the form of 20-30 drops of 1 in 50 
solution of nitrate of silver, or of sublimate solution (1 in 10,000 increasing 
to 1 to 5000), are considered by many French surgeons to be the best 
means of disinfecting the bladder. Much benefit, however, is often 
derived from an injection of a drachm of iodoform emulsion of the 
strength of two scruples of iodoform to an ounce of water. 

The diet must be carefully regulated ; alcohol is to be forbidden. 

In women dilatation of the urethra, vesico-vaginal cystotomy, or 
hypogastric cystotomy, may have to be performed for drainage. Except 
in cases where it is reasonable to expect that the drainage will not long 
be required, the latter operation is to be preferred. In many cases of 
cystitis sanmetto in drachm doses three times a day does excellent service. 
So also does the solution of parsley and kola seed mixed with coca and 
saw palmetto made by Bell and Company of Oxford Street, and named 
by them " liquor petroselini cum serenoa compositus." Tyson recom- 
mends santal oil to be administered before meals, and an injection of 
sodium salicylate (a drachm to a pint) or of alum solution to be used. 

III. Tuberculous Disease of the Bladder. — This is a disease which 



DISEASES OF THE FEMALE BLADDER AND URETHRA 943 

affects the period of activity of the sexual organs, but is met with 
occasionally in children under four years of age, and also in extreme old 
age. It is three times more common in men than in women. 

The general causes are the same as of tuberculosis elsewhere. The 
local are to be found in the frequency of gonorrhoea and other suppura- 
tive discharges, and of infective cystitis which, in persons with this 
proclivity, are apt to pass into tuberculous disease. 

Morbid Anatomy. — The bladder is generally small, shrunken, thick- 
ened, and surrounded by a bed of sclerosed fibro-fatty tissues which 
diminishes the risk of perforation. The mucous membrane is red, irreg- 
ular, and fungous-looking, especially about the trigone and about the 
orifices of the ureters. Minute gray miliary tubercles are occasionally 
seen; they may be more or less confluent, bat do not form the larger 
cheesy masses so often met with in the kidneys, prostate, testes, and 
vesiculse. Ulceration is present in the more advanced stages : the ulcers 
have the characters of tuberculous ulcers of other parts ; they may be 
small and numerous, or a large ulcer may have arisen by the coalescence 
of smaller ones ; their depth varies from mere surface destruction to 
actual perforation. Though perforation is rare, it sometimes results in 
fistulous openings into the rectum, vagina, or perineum ; or, after form- 
ing an abscess in the cavity of Retzius, an opening may be established 
through the hypogastrium. Ulceration may extend through the urethro- 
vesical orifice and invade the urethra. I have met with deep ashy gray 
tuberculous ulcers in the urethra of girls, and also tuberculous abscess 
at the vesical end of the ureter. 

It is very rare for the bladder to be the only part of the genito- 
urinary apparatus affected at the time of death. 

In cases of pulmonary phthisis the bladder is sometimes found in a 
very early stage of tuberculosis without the appearance of any signs of 
its existence during life. 

Symptoms. — The first symptom is frequency of micturition after 
meals and at night. Then the urine is slightly tinted with blood more 
or less, and at longer or shorter intervals. Later still, pain occurs and 
the urine is much thicker and contains pus ; then it is that cystitis 
appears, and, as Tuffier writes, the disease, which till then was " vesical 
tuberculosis," becomes " tuberculous cystitis." So it may last for years 
without very greatly affecting the general health. 

The functional symptoms are (i.) frequency of micturition; (ii.) 
hsematuria ; (iii.) pain ; (iv.) certain morbid constituents of the urine. 
Each of these symptoms must receive a brief notice. The frequency 
of micturition comes on insidiously, and may exist for a long time with- 
out attracting much attention. It is due to a slight congestion of the 
mucous membrane, and increases with its cause, till at length the need 
to pass water becomes very imperious, and occurs every hour, or even 
every half -hour ; and, in the gravest cases, it may be almost continuous 
and tantamount to a condition of "false incontinence," It is generally 
u^orse at night than in the daytime. 



944 SYSTEM OF GYNECOLOGY 

Hsematuria is an early symptom but, like the frequency, it may be 
so slight as to escape the patient's observation for a time. It is com- 
pared to the haemoptysis of pulmonary tuberculosis and, like the fre- 
quency of micturition, is due at first to active congestion of the mucous 
membrane ; later, however, there may be an actual haemorrhage from 
the ulcerated surface. As an early symptom it is spontaneous and slight, 
the urine being faintly pink or rose-tinted throughout ; but a few drops 
of pure blood may issue at the end of micturition. As it comes, so it 
goes, without obvious cause ; it is thus unlike the hsematuria of calculus, 
but like the hsematuria of tumour. In one respect, however, it differs ; 
the bleeding of tumours is free and abundant, the hsematuria of tuber- 
culosis is slight. In the middle stages of the disease the hsematuria may 
cease ; but in the later, if it should recur, it may be very considerable. 

Pain is an indication of cystitis. It is often brought on by sounding, 
after which the three cardinal symptoms of cystitis may appear ; namely, 
frequency of micturition, pain, and pus. In some cases the pain of tuber- 
cular cystitis is by no means severe, and certainly not incompatible with 
the ordinary pursuits of life. In others it is frequent and intense, or 
even continuous and agonising; it precedes, accompanies, and follows 
micturition; and as the frequency of micturition is increased by the 
cystitis, there may be no cessation day or night of the terrible sufferings. 

Sometimes the pains are accompanied by spasm of the membranous 
urethra, and thus temporary retention adds greatly to the distress. In 
the most advanced stage, especially if the neck of the bladder have been 
partially destroyed by ulceration, there may be incontinence of urine. 

Polypoid excrescences sometimes occur about the urinary meatus and 
urethra of women affected by tuberculous disease of the bladder. 

TM Urine. — With the onset of the frequency of micturition there 
is increase in quantity to three or four pints, but the urine remains clear; 
later it may become purulent with the cystitis. Tubercle bacilli are 
found in the first stage, but not when there is much pus. 

Diagnosis. — Vesical tuberculosis ought to be suspected in any case 
in which frequency of micturition, with slight hsematuria, occurs between 
the ages of fourteen and forty-five ; especially if the patient have a tuber- 
culous aspect or family history. If cystitis occur, and the presence of 
tubercle be ascertained in the lungs, generative organs, or other parts, 
the diagnosis becomes pretty certain. 

Some nervous diseases may simulate tuberculosis of the bladder; 
but there will be other evidence of these, and the pains will precede 
the evidence of cystitis. 

Vesical calculus presents a different form of hsemorrhage; and the 
symptoms are allayed by rest in the horizontal position. 

Vesical tumours cause more copious hsemorrhage ; and less marked 
frequency of micturition. 

From cystitis due to other causes, tuberculous cystitis is distinguished 
by the onset and course of the disease, and by the result of examination 
of the urine. There may be some difficulty in making a diagnosis in 



DISEASES OF THE FEMALE BLADDER AND URETHRA 945 

those cases in which, the tuberculosis has followed an old gonorrhoea or 
a deep-seated urethral discharge. 

From tuberculosis of the kidneys and ureters the diagnosis is often 
very difficult. The disease in the bladder progresses very much more 
slowly than in the kidneys. In cystitis the urine is at first, and for a 
long while, much less charged with pus, and that which is first passed 
contains more than the rest of the urine ; and there are not the digestive 
disturbances, the dry tongue, and the rapid emaciation, which are pro- 
duced by the renal disease. 

In women the diagnosis is more difficult than in men. Haematuria, 
rather than frequency of micturition, is likely to be the first symptom 
noticed ; the sexual organs do not give corroborative evidence, and 
cystitis is more often met with in women without obvious cause. In- 
oculation experiments and the inefficacy of general treatment will indi- 
cate the diagnosis. And, in doubtful cases of urinary tuberculosis, the 
thermometer seldom fails to assist us, as the temperature nearly always 
rises. 

Prognosis. — The course of tuberculosis of the bladder is a slow one ; 
acute attacks are frequently followed by periods of amelioration, and the 
disease may last some years. If the tuberculous process itself do not 
reach the kidneys, the end is generally brought about by pyelo-nephritis 
of the common suppurative form. Occasionally tuberculous peritonitis, 
acute phthisis pulmonalis, or acute general tuberculosis, is the immediate 
cause of death. Cold abscesses about the bladder, and the continued 
discharges from the resulting fistulas, help to wear out the patient. 

Treatment. — Surgical treatment based on the radical extermination of 
the microbic cause of the disease has up to the present been disappointing. 

The general and medicinal treatment in the early stages of the disease 
— as regards climate, diet, clothing, medicines, dry frictions, sulphur or 
salt baths, sea voyages, visits to the thermal springs, arsenical prepara- 
tions, creasote, cod liver oil — are the same as in pulmonary phthisis. 
Articles ought especially to be avoided which, through the urine, irritate 
the bladder ; such are all kinds of alcoholic stimulants, curries, spices, 
nux vomica, juniper, and so forth. Thus it is to medicinal, rather than 
to surgical means, that the patient should look for benefit. 

Mercurial " instillations," however, render great service. These in- 
stillations consist of the injection into the bladder of from 10 to 40 drops 
of sublimate solution, varying in strength from 1 in 5000 to 1 in 1000. 
It is claimed for this treatment that it acts not only as a medicinal 
remedy to relieve pain, but as a germicide to kill the microbes; and 
that its value is perceived in early stages by its success in relieving 
frequency of micturition. 

If these means fail, and the bladder becomes very irritable and the 
pains severe, morphia must be liberally administered ; even if required 
to the extent of several grains in the twenty-four hours. Of course the 
dose at first must be small, and the increase must be cautious and 
gradual; but very large doses will ultimately be tolerated. 

3p 



946 SYSTEM OF GYNECOLOGY 

Cystotomy sliould be the last resource, and only employed to relieve 
frequent and severe pain and irritability of bladder. The operation 
which hitherto seems to have afforded most relief has been supra-pubic 
drainage of the bladder, followed in some cases by the application of 
nitrate of silver, or chlorine of zinc, or sublimate solution (1 in 5000) to 
the seat of the disease. 

Injuries to Bladder. — Rupture. — Ruptures of the bladder are of 
three kinds : traumatic ; idiopathic ; and pathological. 

Etiology. — The traumatic are caused either by violence from with- 
out, or by violent muscular efforts on the part of the patient herself : 
the pathological result from ulceration, sloughing, thinning, and sac- 
culation of the parietes; the idiopathic result from the spontaneous 
yielding of the distended bladder, independently of any form of vio- 
lence, or of previous ulceration, sloughing, or tunicary hernise. 

In rupture during labour the distended bladder is compressed between 
two strong muscular forces ; namely, the contracting abdominal parietes 
and the contracting and enlarged uterus. In rupture during the strug- 
gles under anaesthesia, and during powerful muscular efforts, such as 
lifting or pushing, the bladder wall is passive and the rupturing force 
is in the abdominal parietes. 

Traumatic ruptures form the bulk of the intraperitoneal cases and 
of those which are partly intraperitoneal and partly extraperitoneal. 

True idiopathic ruptures, or those which occur when there is no 
disease, and where no violence was used, are very rare. In most cases of 
rupture during urinary retention the bladder gives way under forcible 
muscular efforts as explained above; so likewise in cases of rupture dur- 
ing heavy lifting, parturition, and muscular spasms. Thus this class 
is restricted to certain cases of rupture from simple over-distension by tu- 
mours, retroversion of the gravid uterus, and the like ; to spontaneous 
rupture during alcoholism, erysipelas, fever, hysteria (Dr. J. B. Wil- 
mont's case), and other serious illnesses ; and finally to the foetus in utero. 

In pathological rupture the bladder, weakened at certain spots by 
ulceration or tunicary hernise, gives way under distension ; or it sloughs 
as the result of pressure or inflammation. Eivington collected 9 cases 
of intraperitoneal rupture from retroversion of the gravid uterus ; 2 of 
intraperitoneal rupture from extra-uterine foetation ; and 7 cases (3 in- 
traperitoneal, 3 extraperitoneal, and 1 doubtful) due to ulceration. 

Krukenberg, who has collected 10 cases of rupture from retroversion 
of the gravid womb, and added 1 observed by himself, considers the 
pathology of rupture of the bladder and gangrene of the vesical wall to 
be identical. In some cases protective adhesions on the peritoneal 
surface are formed during the progress of the gangrenous inflammation 
of the coats of the bladder, and then the gangrenous parts may be cast 
off entire or broken up ; otherwise, perforation attends the separation of 
the slough, even without over-distension of the bladder. Rupture may 
also take place suddenly from over-distension before the separation of any 



DISEASES OF THE FEMALE BLADDER AND URETHRA 947 

slough ; or may result from efforts, even the most gentle and careful, to 
replace the uterus. Krukenberg adds that when retention of urine 
persists for ten days or longer, either gangrene or rupture of the bladder 
may occur ; but rupture more frequently. He also gives the warning 
that, if gangrenous portions of the vesical wall have been cast off, no 
attempt should be made to replace the uterus ; but that abortion ought 
to be induced. 

The pressure of a retroverted gravid uterus has caused gangrene of 
the walls of the bladder in several instances. 

Tlie Situation of the Rent. — The posterior surface of the bladder is 
the common site, and the more or less vertical line the common direction 
of the simple intraperitoneal traumatic rupture. This rule, however, is 
subject to many exceptions. In spontaneous ruptures the rent is com- 
monly behind, and is usually small and round. 

The quantity of urine effused into the peritoneal cavity varies, and 
increases as life is prolonged. If death occur within three days a large 
quantity may be present without any signs of peritonitis. Surgical 
casualties in operations on the abdomen have repeatedly shown that 
healthy urine is harmless to the peritoneum, especially if it can find an 
exit ; and, moreover, that it may be rapidly absorbed. Experiments, too, 
show the small quantity of urine injected into the peritoneum is inoffen- 
sive ; that injections may be repeated with impunity ; but that a persistent 
effusion excites peritonitis (Tuffier). On the other hand, when life has 
been prolonged, and septic elements have been introduced by the catheter, 
or have established themselves about the inflamed and contused edges 
of the wound, the evidences of peritonitis will be well marked. 

Diagnosis. — The most certain evidence of intraperitoneal rupture is 
the entrance of a catheter into the peritoneal cavity through the rent 
in the empty bladder. In extraperitoneal rupture signs of urinary extrav- 
asation may appear soon ; but in some cases they are not ap^Darent for 
many hours. 

The injection of a warm antiseptic solution into the bladder may be 
of great use in diagnosis ; if the bladder is sound, the usual swelling of 
a distended bladder will be formed, and will disappear on the return of 
the fluid through the catheter. 

Prognosis. — This is most grave. Walsham has collected 28 cases 
of intraperitoneal rupture of the bladder treated by sutures since 1888 ; 
of this number 11 recovered and 17 died. In only 1 out of the 11 
successful cases was peritonitis present at the time of the operation ; 
whereas in 8, and probably in 9, out of the 17 unsuccessful cases 
peritonitis had set in before the operation was commenced. The causes 
of death in the 8 cases in which peritonitis did not precede the opera- 
tion were shock or haemorrhage, or both combined, in 5 ; peritonitis 
from leakage in 2, if not in 3. In 4 out of 17 cases the rent had not 
been securely closed and leakage occurred. 

Treatment. — The first thing in many cases will be to attend to 
the condition of extreme shock by the application of warmth, gentle 



948 SYSTEM OF GYNECOLOGY 

Stimulation, and the like, requisite in all such, cases. Next must be 
the prompt local treatment to prevent the further escape of urine into 
the peritoneum or pelvic cellular tissue by providing a ready exit for the 
urine as it reaches the bladder by catheter ; and by closing the wound 
in the bladder by sutures when this is possible. And here everything 
depends upon an early and an accurate diagnosis. If the case be one 
of intraperitoneal rupture no time is to be lost (where sufficient assist- 
ance and proper convenience can be obtained for the operation) in 
performing laparotomy, clearing out the urine and blood from the 
peritoneal cavity, and securely suturing the opening in the bladder wall. 

When the surgeon is single-handed, and cannot get assistants or 
appliances within twenty-four hours, let him employ antiseptic drainage 
of the bladder from the outset, and reduce to a small limit the quantity 
of fluid given to the patient for the first three or four days. Para- 
centesis of the abdomen or recto-vesical pouch need hardly, if ever, be 
performed. 

In extraperitoneal ruptures a catheter should be retained in the 
bladder with the most rigid antiseptic precautions, taking care that the 
instrument is large, and that the urine is run off into a vessel, containing 
an antiseptic solution, placed beneath the bed. 

Vesico-vaginal Fistula. — A communication between the bladder and 
either the uterus or vagina, so as to admit of the more or less continuous 
escape of urine, is a condition productive of extreme distress. The size 
of the opening varies from that of a pin's point to a diameter of an inch 
or more. When recent the aperture is usually at its largest, diminishing 
later by cicatricial contraction. At the same time the bladder shrinks, 
and the walls are contracted and thickened. Sometimes the mucous 
membrane of the bladder can be seen to protrude through the opening 
in the vesico-vaginal septum. The urethra is often considerably nar- 
rowed, as a result of disuse, and the edges of the fistula are thickened 
and sometimes held apart by cicatricial fibrous tissue. 

Etiology. — By far the commonest cause of communication between 
bladder and vagina is cancer of the cervix uteri extending to the 
septum, and causing destruction of it. When the disease has reached 
this stage it is beyond the power of remedies; it only remains to 
adopt measures for soaking up the escaping urine and protecting the 
skin. Fistula developing in connection with parturition belongs to a 
different category. It results either from direct laceration or, more often, 
from sloughing, following continued pressure of the foetus within the 
pelvis. Other less frequent causes are necrosis attending diphtheritic 
inflammation of the bladder, and ulceration produced by the long con- 
tinued pressure of a pessary in the vagina. 

Symptoms. — These are chiefly due to the escape of urine by the 
vagina and the consequent irritation of the skin. Besides these, how- 
ever, amenorrhoea, sterility, and constipation are usually present, with 
great impairment of the general health. 

The diagnosis is generally easy. Where the apertures are small or 



DISEASES OF THE FEMALE BLADDER AND URETHRA 949 

concealed the bladder should be distended ^ith milk or some coloured 
fluid, while the vagina is carefully inspected by means of a speculum. 

Treatment consists in paring and suturing the edges, after fully 
exposing the site of the lesion, and in draining the bladder till they 
have united. [^Vide article on Plastic Operations, p. 772.] 

Foreign Bodies. — Foreign bodies gain access to the cavity of the 
bladder (i.) through the urethra ; (ii.) when forced through its Avails by 
injury ; (iii.) by means of ulceration, or the formation of a fistula, which 
is most often of cancerous origin. 

In the first category, by far the greater number are substances intro- 
duced by patients either to allay itching or for some aimless or sensual 
purpose ; the variety of things which have been so introduced is almost 
endless. In the second are found bullets, pieces of bone or of raiment, 
or buttons. Foreign bodies which ulcerate into the bladder, or find their 
way along fistulous tracts, come either from the vagina, the rectum, or 
the higher intestines, from extra-uterine gestation cysts, from dermoid 
cysts, or from abscesses in the pelvic cellular tissue. 

In this way vaginal pessaries have passed through the vesico-vaginal 
septum ; pieces of horn, coins, faecal matter, and intestinal worms have 
entered from the bowel ; fragments of a foetus in extra-uterine gesta- 
tion ; hair and teeth from dermoid cysts ; hydatids ; and pus and bone 
from pelvic abscesses. 

From the observations of Guyon and Henriet it appears that, when 
once fairly within the cavity of the bladder, foreign bodies occupy most 
frequently a transverse position between the summit and the neck of the 
bladder, and rather nearer the neck. In the empty bladder this posi- 
tion is more constant than in the full bladder ; in the empty bladder it is 
the only position which bodies not longer than ten centimetres can take. 
Smaller bodies can occupy any position in the distended bladder ; but in 
the empty, or nearly empty organ, they assume the line of the transverse 
diameter. A body of twelve centimetres in length takes a vertical posi- 
tion, or, if one of its ends is buttressed near the neck, it may lie obliquely. 
Light bodies float ; hollow ones, such as apiece of tubing or of a catheter, 
generally lie in the base of the bladder. Some become disintegrated and 
are passed in particles, perhaps even without the patient's knowledge. 

Foreign bodies, when in the bladder, may remain entirely quiescent, 
or they may excite cystitis ; after a time they may cause ulceration and 
perforation, and, giving rise to a perivesical abscess, may escape by the 
direction through which the abscess is either opened or spontaneously 
discharged. Or the foreign body, having penetrated the vesical wall, 
may remain partly within the bladder and partly within the peritoneal 
cavity. The foreign bodies become encrusted with phosphates, and are 
then often the nucleus of a stone. This deposition begins, in some in- 
stances even within twenty-four hours, upon the largest part of the 
foreign body and proceeds towards the extremities ; these parts, however, 
never become encrusted. 



950 SYSTEM OF GYNECOLOGY 

Symptoms may be entirely absent ; but, as in the case of calculus, the 
rule is for the patient to have pain and frequent micturition, and possibly 
to discharge a little blood at the end of micturition. Hair and other 
rough or sharp bodies are apt to excite cystitis with its attendant 
cardinal symptoms. 

If the foreign body penetrate the cellular tissue and form an abscess 
in the pelvis, the local and constitutional signs of inflammation and 
suppuration ensue. If they penetrate into the rectum there will proba- 
bly be rectal tenesmus 5 if into the peritoneum or small intestines, signs 
of peritonitis will most likely occur. 

Diagnosis. — When the foreign body has been introduced by the 
patient the readiest road to a correct knowledge of the case is the frank 
admission of the patient ; but she often denies any knowledge of what 
she herself has done. 

In surgical accidents, such as catheters breaking off in the bladder, 
there is no room for doubt. In traumatic cases there is the history of 
the injury and the presence of a wound or scar. In perforation of the 
vaginal septum, there is the history of local pain, and probably the 
existence of the ulcerated aperture or its scar. When the foreign body 
has passed through from the intestinal tract there may be, or may have 
been, the escape of gas, fseces, or ingesta along the urethra. 

In the case of hysterical women, however, it is necessary to bear in 
mind that all sorts of things are designedly mixed with the urine. 

Hydatids passed with the urine will give the clue to their presence 
in the bladder. 

It is of great importance, especially with a view to its extraction, to 
learn, if possible, the shape and size of the foreign body, and the length 
of time it has been lodged in the organ. In all cases of doubt the sur- 
geon should examine the bladder (a) by the finger in the rectum, in the 
vagina, or passed into the bladder through the dilated urethra, (h) by 
sounding, and (c) by the cystoscope. 

Treatment. — If the foreign body has been recently introduced, and 
it is soft and pliable, like a piece of tube or gum-elastic catheter, it can 
readily be extracted by the lithotrite, no matter how it is seized by the 
blades of the instrument. Hard, rounded bodies can also be easily 
extracted by the lithotrite ; either with or without breaking them into 
fragments. Elongated substances, whether blunt or sharp, give great 
trouble because of the difficulty of catching them in their long axis. 
The cystoscope will often be of great value in this respect by informing 
us of the direction in which the body lies. Some bodies, such as a 
hairpin, for example, may be luckily caught at their curved ends and 
withdrawn by means of a blunt hook at the end of a flexible stem. 

When the foreign body has become encrusted with calculous matter, 
some advise that the deposit should be detached by the lithotrite, and the 
foreign body extracted in the same manner as if it had only recently been 
introduced; and that the calculous matter should then be removed as in 
litholapaxy. This, however, is by no means always easy ; and sometimes 



DISEASES OF THE FEMALE BLADDER AND URETHRA 951 

it is quite impossible to detach, the calculous matter thoroughly from the 
foreign body : on the whole, it is the better practice in most cases cf 
calculous formation to remove the foreign body by operation, without 
attempting the double procedure with the lithotrite and extraction 
instrument. 

Bodies, such as twigs of trees, are very dangerous, as they are liable 
to be broken, and their leaves or broken particles may cling to, or stick 
into the mucous membrane, whence they cannot be dislodged either by 
instruments or irrigation. Cystitis is very apt to arise and to be followed 
by ascending suppuration and death from pyelo-nephritis. This compli- 
cation, of course, may occur in the case of other foreign bodies. 

In women it will be rarely necessary to resort to any cutting oi^era- 
tion, as the dilatability of the female urethra allows the extraction of 
most foreign bodies which can enter the bladder. 

After extraction the treatment is the same as after extracting an 
ordinary calculus, and will vary according to the presence or absence of 
cystitis. 

jSTeoplasms. — New growths of the bladder present numerous histo- 
logical varieties and considerable clinical differences. Clinically, some 
are benign and others malignant ; histologically, the benign comprise 
papilloma, myxoma, fibroma, and myoma. The malignant are carcinoma 
and sarcoma. 

The following table shows the relative frequency of malignant and 
non-malignant new growths in the bladder : — 





Total. 


Males. 


Females. 


Cancer 


59 


43 


16 


Sarcoma 


6 


5 


1 


Fibroma 


2 


1 


1 


Papilloma (villous) . 


23 


21 


2 




90 


70 


20 



There are some characters common to all bladder tumours. Their 
usual situation is about the trigone and the orifice of the uterus. Benign 
tumours are generally rounded, often polypoid or tufted ; the malignant 
tumours are more generally spread out. 

Their size varies from that of a cherry to that of an Q%g\ larger 
growths are rare, and are generally myoma. 

Cancerous and sarcomatous tumours are not unfrequently multiple, 
the masses being apparently independent of one another. 

Tumours may be embedded in the vesical wall, or sessile, or pedun- 
culated on its surface ; or they may infiltrate it. 

Papilloma is of two kinds, the fimbriated or "villous polypi," and 
the fibro-papillomas, or "papillary tumours." In the villous polypi the 
stalk sends off numerous branches and sub-branches of polypi, which 
consist of a capillary vessel covered by a basement membrane and a 



952 SYSTEM OF GYNECOLOGY 

more or less thick layer of epithelium ; in the papillary tumours the 
stroma is compact and has a dense fibrous or muscular structure, amongst 
which may be found embryonal cells and leucocytes. The villous polypi 
are very frequently multiple, and form tufts or feathery bunches of vary- 
ing lengths more or less spread over the mucous surface ; these float 
in the urine. When very long their extremities are often carried into 
the urethro-vesical orifice during micturition and are there nipped by 
the sphincter : this is a cause of considerable suffering. There is no 
infiltration of the vesical wall about their points of attachment. The 
papillary tumour or " fibro-papilloma " may be single or multiple ; it is 
generally rounded in shape, and of the size of a pea, a cherry, or a wal- 
nut. It is more often sessile than pedunculated ; its surface is villous, 
but its consistence is firm. 

Myxoma is in reality a '^ fibro-papilloma," or a fibroma, the cell por- 
tions of which have undergone a mucoid degeneration. These tumours 
are soft in texture, grow rapidly, and are met with most frequently in 
young children. They are probably often congenital, frequently multi- 
ple and pedunculated ; their common situation is near the neck of the 
bladder, and they may extend into the urethra. 

Fibroma originates in the deep mucosa or in the muscular layer, and 
is covered by normal epithelium. Like myxoma, these growths are 
pedunculated ; but they occur in adults, and have not yet been found in 
children. They are very rare. 

Myoma.s are rare ; two cases reported by Belfield show indisputably 
that they may arise from the vesical wall. They occur as nodules en- 
capsuled in the snbmucosa ; they may be composed either of unstriped 
muscular fibres (myoma), or of this mixed with fibrous tissue. 

Sarcoma is comparatively rare, but its rarity has probably been 
greatly exaggerated. 

Carcinoma. — Two varieties are met with: (i.) epithelioma, that is, 
squamous-celled carcinoma, or cylindroma; and (ii.) glandular-celled 
carcinoma, either encephaloid or scirrhous. Colloid degeneration of 
the glandular-celled carcinoma may occur, but is rare. 

Secondary carcinoma is more frequent than primary, and may be 
consecutive to cancer of the rectum, vagina, or uterus. These tumours 
form prominent, irregularly rounded swellings, widely attached, and 
infiltrating the vesical coats more or less deeply. Their surface is 
granular, and in the later stages is ulcerated ; occasionally they present 
gaping ulcers with raised and indurated walls. They are hard, but 
friable ; and therein differ from the softer but little friable fibro-papil- 
lomas. They are often multiple, and are most common in the trigone 
or base of the bladder. They develop slowly, seldom ulcerate early, and 
cause death before they attain any great size; often before they are 
followed by secondary growths in distant organs. 

Some tumours which have been exceptionally found in the bladder 
are adenoma, angeioma, serous cystoma, and dermoid cystoma. The latter 
is probably due either to an abnormal development of the bladder wall, 



DISEASES OF THE FEMALE BLADDER AND URETHRA 953 

by which a portion of the epiblast fills in a deficiency, or they are peri- 
vesical in origin. 

Mucous polypi, having a texture resembling that of ordinary nasal 
polypus, except that the epithelial covering is squamous instead of 
ciliated, have been found in the bladders of children under two years 
of age, as well as in adults. In the early stage they may not give rise 
to any symptoms ; later they may simulate vesical calculus, and growing 
to a considerable size project even beyond the urethra, or distend the 
bladder to the level of the umbilicus. 

Billiarzia hcematobia sometimes causes masses of fungating exuda- 
tion of considerable size in the bladder. It is not an uncommon cause of 
hsematuria in the Nile district. [Art. " Bilharzia " in Syst. of Med. vol. ii.] 

Pathological complications of bladder tumours are: (i.) local thicken- 
ing of the bladder walls due to hypertrophy of muscular and interstitial 
tissue ; (ii.) hydronephrosis ; (iii.) calcareous deposit on the surface of 
the tumour ; (iv.) occasionally a phosphatic calculus free in the bladder, 
the result of a cystitis provoked by the growth, possibly a portion 
of the growth broken away from the rest may form its nucleus ; 
(v.) suppurative pyelo-nephritis with or without distension of the kidney. 

Symptoms. — Bladder tumours are met with at all ages, the sarcomas 
and myxomas in children ; cancer between forty and sixty. They are 
much more common in men than in women. 

A small number of tumours of the bladder are quite unsuspected 
during life, as large calculi have been found as a surprise in autopsies. 
But as a rule their presence is made only too apparent by haemor- 
rhage, pain, frequency of micturition, and, not unfrequently, by the 
presence of a swelling felt either through the vagina or through the 
anterior abdominal wall. Haematuria is by far the most constant 
symptom ; in some cases it is the only one, and sometimes is alone the 
cause of death. It is nearly always the first symptom complained of, and 
the one which brings the patient to his doctor. Its onset, its course, and 
its abundance are characteristic of tumour. It comes on spontaneously 
without injury, fatigue, or even movement ; and it causes no difficulty in 
micturition unless a clot for a while obstruct the urethra. It may be 
excited by catheterism or by distension of the bladder; and rest even in 
the recumbent position has no effect in stopping it. After the hsematuria 
has existed for hours, days, or weeks, the urine may suddenly become 
quite clear. 

Whilst the hsematuria lasts, the urine is not equally charged with 
blood at each micturition ; more blood is passed at the end of micturition 
than at any other period of its flow : the quantity is often exceedingly 
great, and the loss, even from a small innocent growth, may be fatal. In 
cases of repeated or prolonged haemorrhage the patient becomes anaemic 
and waxen looking, and the lower extremities oedematous. 

Pain is not a constant symptom ; it appears late, and is generally due 
to cystitis. When it exists it is often very intense, and is worse at the 
end of micturition. It is felt in the hypogastrium and at the neck of the 



954 SYSTEM OF GYNAECOLOGY 

bladder, and radiates down the thighs. But, except from cystitis, from 
nipping of the growth by the sphincter vesicae, or from retention due to 
clots of blood, pain occurs only when the growth is pressing upon the 
nerves as it infiltrates the bladder wall. 

Physical signs are those ascertained by abdominal or vaginal examina- 
tion, by the endoscope, by injecting fluid into the bladder to the degree 
of distension, and by the catheter. If these means afford positive 
signs, well and good ; but if not, we must not exclude tumour from 
our diagnosis, if the above described functional symptoms be present, 
especially hsematuria. With the patient lying on her back, with her 
knees and shoulders raised, we can, in a thin person, sometimes feel 
the tumour through the abdominal walls immediately above the pubes. 
Still more frequently can it be felt by vaginal examination, especially 
if at the same time the bladder be firmly pressed upon by the left hand 
applied on the hypogastrium. The result of this kind of examination 
may be positive or negative. It may be negative if the growth be 
either villous polypus or fibro-papilloma, or a small pedunculated 
myxoma-fibroma ; but if we feel an irregular nodular or infiltrated 
vesical wall or thickened mass above the neck of the bladder, we know 
the disease is malignant. Mucous polypi, when large and abundant, 
have also been felt on the application of pressure to the hypogastrium. 

It is well always to examine the urine first passed after this kind of 
examination ; for when tumour is present the examination is often 
followed by slight haemorrhage. 

The catheter and sound ought to be used with the greatest care ; not 
only as to their aseptic condition, but with deftness so as to avoid 
bruising the tissue of the tumour and provoking haemorrhage. 

Diagnosis. — This can generally be made pretty accurately (1) by 
the character of the haemorrhage ; (2) by the physical signs described 
above ; (3) by the cystoscope or tube which in certain cases enables the 
new growth to be actually inspected; (4) in the woman, by digital ex- 
amination per urethram, which affords absolute certainty as to the 
presence or absence of growths, even the smallest ; and this should be 
preferred to all other methods. 

If a tumour of some weight or volume be detected, or a general 
thickening or infiltration of the base of the bladder exist, we conclude 
that the growth is malignant, and the prognosis very serious. 

The distension of the bladder with a solution of boric acid or weak 
carbolic solution, if it excite haemorrhage as the last drops flow away, 
is a valuable diagnostic guide to the vesical origin of haematuria. 
Sometimes, especially if the growth be near the neck of the bladder, 
a drop or two of blood flows through the injection catheter, either as it 
enters the vesical cavity or as soon as the injecting process ceases. 

The cystoscope in some cases gives most valuable information; but 
it is useless in cases in which there is blood in the bladder, and it ought 
not to be used upon all patients indiscriminately. 

The chief difficulty in most cases is to determine whether the 



DISEASES OF THE FEMALE BLADDER AND URETHRA 955 

lisematuria be of renal or vesical origin. This may be decided by the 
presence of local signs in the renal or vesical regions, by the presence of 
renal or ureteral casts, and by a consideration of the several symptoms. 
The difficulty is accentuated when both regions, or neither, yield positive 
evidence. We must then have recourse to distension of the bladder, or 
sounding ; if this provoke haemorrhage we have proof of vesical disease. 

From the haemorrhage attending acute and chronic cystitis, tuber- 
cular disease of the bladder, and calculus, the diagnosis will be readily 
made by a careful attention to the history of the case, and to the cardinal 
symptoms of the respective diseases. 

There are cases of hcematuria in which it is impossible to be sure 
of the source of the bleeding ; in some it is due to congestion and vari- 
cosity of the vessels of the bladder. 

Prognosis. — This is always serious. The malignant growths are 
unfavourable for removal, as they infiltrate the vesical walls and quickly 
recur. The benign tumours are often easily removable; but some, 
especially the villous polypi, are prone to come again. Then there is the 
danger from haemorrhage, which may be fatal ; from cystitis running on 
to pyelo-nephritis, or from intermittent hydronephrosis. These causes 
of death arise from innocent as well as from malignant growths. 

As to the duration of life. Fere gives for malignant tumours eighteen 
months to two j^ears. Barling three years ; whereas Guyon has operated 
upon patients for epithelioma in cases in which the first symptoms of 
bladder tumour dated back ten years previously. Such cases indicate 
either that cancer progresses much more slowly in the bladder than 
elsewhere, or that tumours, benign at first, can subsequently become 
malignant. We know this to be the case in uterine myoma, and in 
tumours of other kinds in other parts of the body. 

Vesical malignant growths infect other parts or organs but slowly ; 
death is by no means invariably due to secondary invasions. 

The benign growths may go on for years, causing only occasional 
haemorrhage at longer or shorter intervals, and of greater or less sever- 
ity. I have known cases go on for ten years or more ; and when at last 
an operation has become absolutely necessary, a mass of villous polypi 
enough to fill a breakfast cup has been removed. 

Tumours of the bladder, if left alone, almost always cause death ; 
though their progress, especially in the benign cases, may be very slow. 
It is mostly by haemorrhage that the fatal result is brought about ; in 
other cases by pyelo-nephritis, the sequel of cystitis. 

Treatment. — The best palliative means are incision and drainage 
of the bladder ; the only curative means is, of course, excision of the 
tumour. 

In woman the best incision for palliative purposes is through the 
vesico-vaginal septum ; sutures should unite the vesical with the vaginal 
mucous membrane over the edges of the incision, so as to secure a per- 
manent opening. 

When the bladder wall is not largely involved, and if the condition 



956 SYSTEM OF GYNECOLOGY 

of the kidneys does not forbid, the curative treatment should be carried 
out if possible ; if, however, after opening the bladder, the disease is 
found to be too extensive for removal, the surgeon must fall back upon 
palliative means. 

When a growth is felt, per vaginam or with the sound, to involve a 
large surface of the bladder wall, and to be infiltrating its coat, espe- 
cially in the neighbourhood of the ureters and neck of the bladder, no 
operation whatever should be proposed unless the haemorrhage be copious 
or the symptoms of cystitis severe ; then an incision, for palliative pur- 
poses only, should be made. This should be the vesico-vaginal bouton- 
niere. By these means we place the bladder at rest ; thus, by drainage, 
we remove the septic urine from an inflamed bladder ; and, by prevent- 
ing the alternation of distension and contraction of the bladder which 
is the chief cause of the bleeding, we check the haematuria. When the 
disorganised state of the kidneys is unfavourable to any prolonged 
operation, the vaginal drainage is still indicated to check haemorrhage, 
or for the relief of the sufferings caused by cystitis. 

Urethral dilatation enables many tumours to be removed easily and 
thoroughly through the canal ; and as the urethra can be dilated to 
between two and three centimetres without fear of after ill consequences, 
this route is the most satisfactory for the majority of cases suitable for 
curative treatment. Where the growth is too large to be removed 
through the female urethra, hypogastric cystotomy should be performed. 
It must suffice here to say that the methods for removing the growths 
are by — (a) tearing them away, (6) crushing them off with forceps or 
ecraseur, (c) curetting, (cZ) cauterisation, (e) excision with the bistoury 
and closing the wound in the mucous membrane by sutures, or searing 
the surface with the cautery, (/) torsion. 

Tuffier records 43 operations through the urethra without a death, 
and 5 suprapubic operations all successful. 

Stone in the Bladder. — Vesical calculus is rare in women, because 
owing to the shortness and dilatability of their urethra, calculi which 
can traverse the ureter can easily escape from the bladder. Moreover 
gravel and gout are much less frequent in women than men. 

Local causes of the formation of stone in the bladder are all those 
which tend to the stagnation of urine in the bladder and to the develop- 
ment of cystitis. When these two conditions, decomposition of urine 
and cystitis, occur together, as so often they do, the ammonia-magnesian 
phosphates are precipitated. This precipitation may occur spontane- 
ously, and thus lead to the formation of a primary vesical calculus ; or 
it may take place even more readily around a concretion which has 
descended from the kidney ; and this is the process by which uric-acid 
calculi become enveloped in a white casing of the phosphates. 

It is by this same precipitation of the phosphates that foreign bodies 
in the bladder become encrusted with salts, and calculi are formed with 
such things as blood-clots, pieces of bone, hairpins, twigs of trees, berries, 



DISEASES OF THE FEMALE BLADDER AND URETHRA 957 

and so forth, as their nuclei. In the same way, too, the surface of 
vesical tumours and the ends of catheters retained in the bladder be- 
come encrusted with a more or less thick white layer. 

Chemical Composition. — There are three chief classes of vesical cal- 
culi : (i.) The most frequent are formed of uric acid and its combina- 
tions ; (ii.) the next in frequency of phosphoric acid in combination with 
volatile alkali and the alkaline earths; and (iii.) those of oxalate of lime. 

The symptoms are pain, frequency of micturition, and haemorrhage. 
To these may be added — (a) the sudden interruption of the stream of 
urine, a symptom to which, however, undue importance is often given ; 
(6) the patient's clinical history, especially as to the passage of gravel 
or sand ; and (c) the previous occurrence of an attack of nephritic colic, 
not followed by the discharge of a calculus. 

Examination per vaginam enables us to feel a stone or stones, and 
also to judge as to their number and size ; especially when firm pressure 
is made on the bladder above the pubes. But it is by means of the 
sound that we gain the more precise information. 

Prognosis. — The supervention of septic infection of the bladder, 
whether any operation have been done or not, creates the danger of 
calculus, and, as ascending suppurative pyelo-nephritis, conduces to the 
fatal result. The existence of this condition before the operation adds 
largely to the risks of surgical interference, and to the prevention of it 
is attributable the mortality, small though it be, which follows lithotrity 
as now practised by skilled hands. 

The spontaneous expulsion of calculi in the case of men cannot be 
reckoned upon ; but women pass large stones through the urethra, and 
others still larger sometimes escape into the vagina by ulceration of the 
vesico-vaginal septum. 

Treatment. — In women, owing to the absence of the prostate, lithot- 
rity is said to be more difficult than in man ; but this applies only to 
the operation in hands inexperienced in lithotrity in males. Lithotrity 
is, however, rarely required in women, because of the capacity and 
dilatability of the urethra. In Avomen with stone of a large size vaginal 
cystotomy, followed by immediate sutures, is an easier, safer, and more 
satisfactory operation than the hypogastric operation. In female chil- 
dren, the best operation is lithotrity by means of a lithotrite of the cali- 
bre of a full-sized catheter (No. 12 or 14), followed by the evacuation 
of the fragments with Clover's or Bigelow's evacuating bottle (aspi- 
rator) ; and in adult women the same operation may be employed for 
stones which are too large to be safely extracted through the urethra in 
their entire state. Or the fragments of the stone may be removed with 
forceps through the dilated urethra. The operation is allied to the 
mixed operation in males. 

Henry Morris. 



958 SYSTEM OF GYNECOLOGY 



REFERENCES 

1. American Journal of Obstetrics. — 2. Annales des maladies des organes genito- 
urinaires. — 3. Archives fur Gynaecologic. — 4. Bavoux, H. Des polypes de I'urethre 
chez la femme. Strasbourg, 1844. — 5. Brechot, A. Des tumeurs de I'urethre chez la 
femme. Paris, 1876. — 6. Civiale. Maladies des organes genito-urinaires. — 7. Dautin, 
E. Du diagnostic de quelques eculements nrethraux chez la femme. Strasbourg, 
1869. — 8. Dell' AcQUA, P. Historia Fhlegmhymen proptoseos urethrse. Ticini Regii, 
1830. —9. DoLLEZ, C. A. Des polypes de Vurethre chez la femme. Paris, 1866. — 10. 
DupiN, O. P. Sar les vegetations hemorrhoidales de Vurethre chez la femme. 
Paris, 1873. — 11. Ehrhardt, E. Ueber chronische Ulcerationen an der weiblichen 
Harnrohre. Berlin, 1884. — 12. ]^tiennb, P. De Vurethre de la femme, etc. Nancy, 
1880. — 13. Fantorie and Mollinetti. Phil. Trans, vol. vii. — 14. FissiAux, E. 
Des 7'^trecissements de Vurethre chez la femme. Paris, 1879. — 15. Fleyssac, C. E. 
De quelques tumeurs de Vurethre chez la femme et principalement des tumeurs hemor- 
rhoidales. Paris, 1879. — 16. Flotard, D. De la dilatation de canal de Vurethre 
chez la fetnme. Montpellier, 1882. — 17. Gant. Diseases of the Bladder, Prostate 
Gland, and Urethra. London, 1884. — 18. Gottschalk, S. Ueber die weibliche 
Epispadie. Wiirtzburg, 1883. — 19. Guebhard. Etude sur la cystite tuberculeuse. 
Paris, 1878. — 20. Guyon, J. C. F. Le(;ons cliniques sur les affections chirurgicales de 
la vessie et de la prostate. Paris, 1888. — 21. Hache. Etude clinique sur les cystites. 
1884. — 22. Harrison, R. AshursVs Surgery, vol. vi. 1886.-23. Hartmann. Des 
cystites douloureuses et de leur traitement. These, 1887. — 24. Mauer, Otto. Ueber 
die Exfoliation der Blasenschleimhaut. Berlin, 1880. — 25. Maurice, V. Histoire de 
la dilatation rapide de Vurethre chez la femme. Nancy, 1877. — 26. Morris, H. 
Injuries and Diseases of the Genital and Urinary Organs. London, 1895. — 27. 
MiJNZNER, M. Ueber Vorfall der Schleimhaut der weiblichen Harnrohre. Ehrlangen, 
1858. — 28. NiTZE, M. Kystophotographischer Atlas. Wiesbaden, 1894. — 29. Notta. 
" Observations de corps etrangers introduits dans la vessie et^ dans le canal de 
I'urethre," Annee med. 1877-8-9. Caen. — 30. Nunez, J. E. Etude sur les vices 
de conformation de Vurethre chez la femme. Paris, 1882. — 31. Picard, H. Traite 
des maladies de la vessie et des V affections calculeuses. Paris, 1878. — 32. Piedpre- 
MiER, F. Contribution a V etude des maladies de Vurethre chez la femme ; m^ethroceles 
vaginales. Paris, 1887.-33. Reichelt, P. W. Ueber Prolaps der Uretralschleimhaut 
beim Weibe. Halle a. S. 1886. — 34. Silbermann, O. Die briiske Dilatation der 
weiblichen Harnrohre. Breslau, 1875. — 35. Skene. Diseases of the Bladder and 
Urethra in Woyyien. New York, 1878.-36. Soullier, L. Du cancer primitif du 
m^at urinaire chez la femme. Paris, 1889.-37. Thompson, Sir H. Tumours of the 
Bladder. London, 1884. — 38. Tritschler, E. Ueber der Vorfall der Schleimhaut 
der weiblichen Harnrohre im kindlichen Alter. Tiibingen, 1891.-39. Tuffier. 
Appareil urinaire. Traite de chirurgie. Duplay et Rectus. Paris, 1892.— 40. Uebers- 
CHuss, H. Beitrdge zu der Lehre von den primdren Carcinomen der weiblichen Urethra. 
Wurzburg, 1892. — 41. Voillemier, A. le D. Traite des maladies des voies urinaires. 
Paris, 1881. — 42. Walsham. Royal Med.-CMr. Soc. 11th June 1895.-43. West and 
UuNCAN. Diseases of Women. London, 1879.— 44. Winckel. "Die Krankheiten der 
weiblichen Harnrohre und Blase," Billroth's Handbuch. Stutgard, 1877. 

Tumours of the Urethra. — Henry, A. F. Paris, 1858. — Jondeau, A. Paris, 1888. 
— Keilmann, H. Wiirzburg, 1886. — Lemoinb, V. Paris, 1866.— Menetrez, A. Paris, 
1874. — MouTON, E. G. Paris, 1876. — Thevenon, L. A. Paris, 1879. — Velten, P. F. 
Paris, 1862. — Weisgerber, A. Paris, 1877. 

H. M. 



LIST OF AUTHORITIES 



Abel, 652, 694, 728, 732 

Ackermann, 605 

Adam, 642 

Adami, 445 

Adams, 411 

Aetius, 22 

Agnew, 929, 930 

Aitkin, 535 

Alexander, 18, 411 

Allbutt, 7, 224, 249, 341 

Allingham, 263 

Amann, 420, 843 

Amussat, 604 

Anderson, 487 

Ansell, 563 

Apostoli, 13, 14, 28, 300, 305, 306, 307, 

316, 321, 322, 324, 325, 329, 333, 335, 

336, 597, 598 
Aran, 486, 554, 919 
Asch, 549 
Aslanian, 592 
Atlee, 10, 604 
Atthill, 209, 264, 265, 293 
Auteureich, 841 
Auvard, 295, 679, 687 
Aveling, 29, 341, 923, 924 

Baer, 621, 622, 623, 624, 628 

Baff, 891 

Baldy, 297, 298, 531 

Ballance, 269 

Ballantyne, 812 

Bandl, 4, 534, 535, 539, 546, 547, 552, 799 

Bantock, 12, 276, 584, 622 

Barbour, 3, 4, 23, 534, 535, 544, 771 

Bardenhauer, 621, 627 

Barling, 955 

Barlow, 534 

Barnes, 209, 250, 253, 277, 293, 472, 525, 

532, 533, 539, 915, 919, 920, 922 
Barrier, 920 
Barrow, 276 

Barth, 801, 805, 813, 816, 824 
Battey, 11, 601 
Baudry, 435 
Bayle, 562 
Bayliss, 342 
Beau, de, 339 



Becqueril, 528 

Beidel, 384 

Beigel, 528 

Belfield, 952 

Bell, 8, 295, 873 

Benicke, 370 

Bennet, 5, 189, 190, 199, 211 

Bernard, 341 

Bernardet, 936 

Bernays, 586 

Bernhardt, 707 

Bernutz, 22, 23, 486, 525, 526, 527, 528, 

531, 532, 534, 535, 536, 540, 555 
Berry, 341 
Beyea, 794 
Bickersteth, 806, 807 
Bigelow, 957 
Billroth, 19 
Birschoff, 383 
Blanc, 447 
Blau, 697 
Blot, 67, 71 
Blundell, 639, 700 
Bodd, 342 
Boinet, 872 
Boldt, 592 
Bouchart, 340 
Bourdon, 22, 524 
Bozeman, 286, 477, 599, 773, 778 
Braithwaite, 281 
Brandt, 405, 522 

Braun, 209, 525, 546, 550, 557, 654 
Breisky, 384 
Brennecke, 192, 712 
Breslau, 525 
Breunicke, 622 
Broers, 443 
Brown, 230 
Brown, Baker, 8, 603 
Browne, 921 
Bryan, 942 
Biicheler, 694 
Buck, 290 
Buckmaster, 94 
Budin, 285, 286 
Bumm, 207, 660 
Burkle, 694 
Burns, 19 



959 



960 



SYSTEM OF GYNECOLOGY 



Busch, 68 
Busey, 918 
Byford, 624 
Byrne, 528 

Cabade, 341 

Cabot, 577 

Calvi, 22 

Campbell, 339, 340, 472 

Caradic, 91 

Cart, 798 

Carter, 465, 480 

Casati, 341 

Cavallini, 639 

Chaffey, 793, 794 

Chambers, 277, 278, 871 

Chambon, 873 

Championni^re, 809 

Champneys, 28, 29, 281, 362, 469 

Chapman, 257, 342 

Charcot, 224 

C harrier, 594 

Chassaignac, 543 

Cheston, 472 

Chiari, 715 

Cliiarleoni, 91 

Choux, 798 

Chrobak, 621, 624, 626, 627 

Church, 18 

Churchill, 22, 200, 263 

Civiale, 936 

Clark, J., 18 

Clark, Sir Charles, 18, 19 

Clay, 8, 10, 873 

Clover, 283, 631, 764, 919, 957 

Coblenz, 62, 805 

Coe, 800, 824, 825 

Cohnstein, 711, 713 

Collins, 289 

Colomiatti, 71 

Colucci, 293 

Conheim, 563 

Cook, 341 

Cooke, 476 

Cornil, 204, 205, 214, 215, 679, 822, 823 

Courty, 293, 925 

Coussat, 590 

Cramer, 102 

Crampton, 911, 914, 917 

Cr6d^, 525, 552, 912 

Cripps, 268 

Crosse, 912, 915 

Cruveilhier, 573, 585, 592, 841 

Cullen, 796, 799 

Culling worth, 24, 35, 534, 571, 590, 793, 

818, 819, 820 
Cusco, 274, 275 
Cutter, 325 
Czempin, 192, 346 

Darwin, 113 

Del^pine, 681 



Delaporte, 873 

Demons, 808, 809 

Denver, van, 341 

Depage, 74, 75 

Dessaignes, 434 

Dezeimeris, 463, 464 

Diamant, 341 

Doderlein, 207, 385, 623 

Dodd, 342 

Doherty, 22 

Dolbeau, 535, 545 

Doleris, 286, 797, 805, 810, 811, 820, 876 

Doran, 12, 16, 25, m, 85, 470, 471, 506, 
810, 811, 816, 840, 842, 845, 846, 848 

Doyen, 621, 628 

Dubois, 932 

Du Chemin, 582 

Dudley, 623 

Duffin, 8 

Duhrssen, 57, 522, 724, 764, 765, 768 

Duke, 290, 295, 752, 754 

Duncan, Matthews, 7, 22, 23, 25, 27, 98, 
195, 201, 232, 236, 263, 282, 374, 429, 
433, 435, 452, 485, 525, 528, 533, 543, 
544, 547, 557, 573, 606, 730, 852, 853, 
860, 913, 914, 920 

Duncan, W., 693 

Dupuytren, 899, 900, 932 

Durand, 96 

D wight, 92 

Dybowsky, 697 

Earl, 820 

Eastman, 621, 624, 626, 627 

Eberth, 804, 814, 816 

Edebohls, 627 

Edelmann, 304 

Edge, 522 

Edmunds, 269 

Eisenmann, 75 

Ellinger, 288, 364 

Embling, 341 

Emmet, 77, 189, 201, 218, 497, 533, 541, 
563, 600, 604, 677, 748, 756, 763, 765, 
766, 767, 768, 772, 774, 776, 919, 924 

Englemann, 27, 366 

Eve, 799 

Fabricius, 816 
Ealk, 69 
Fantoni, 929 
Farre, 49, 389 
Fasbender, 370 
Fearn, 813, 818 
Fehling, 589 
F^nerley, 525, 533 
F6r^, 955 

Fergusson, 264, 266, 908 
Ferraresi, 70 
Fischel, 197, 198, 846 
Fitch, 877, 883 
Flaischlen, 846 



LIST OF AUTHORITIES 



961 



Flower, 44 

Fochier, 740 

Fordyce, 91 

Formad, 825 

Fowler, 447 

Frankenhauser, 552 

Frank, 95 

Franklin, 476 

Freund, 426, 428, 430, 585, 700, 712, 761, 

850, 919 
Fritsch, 20, 209, 214, 215, 286, 290, 362, 

531, 599, 622, 692, 698, 705, 706, 714, 

722 
Frommel, 805 
Fuhrer, 846 
Fiirst, 73, 84, 731 

Galabin, 282, 476, 924 

Gallard, 531, 533 

Garceau, 519 

Gardner, 290 

Gariel, 919, 922 

Geddes, 113 

Gegenbauer, 114 

Gemmel, 583 

Gervis, 294 

Godart, 811 

Godlee, 825 

Godson, 282, 479, 638 

Goelet, 336 

Goffe, 623, 624 

Gonner, 207 

Gooch, 188, 211, 212 

Goodell, 229, 253, 282, 287, 288, 290 

Gosset, 17 

Gottschalk, 192, 202, 207, 735, 736, 738, 

837 
Gould, 30 

Goupil, 23, 525, 555 
Gu^rin, 534 
Gulland, 57 
Gurlt, 561 
Gusserow, 21, 557, 563, 589, 606, 650, 

656, 658, 679, 683, 697, 713, 715, 717, 

728 
Guyon, 570, 938, 949, 955 
Grandin, 88 
Gravel, 78 

Greenhalgh, 292, 603 
Griffin, 274, 275 
Griffith, 478, 679, 851, 852, 865 

Hagedorn, 688, 748, 761, 885, 893 

Hall, 586 

Hamilton, 143 

Hardie, 573 

Harding, 341 

Harle, 340 

Harris, 340 

Hart, 4, 23, 465, 466, 467, 534, 544, 756, 

771, 806 
Hartmann, 694, 818 



Haultain, 72 

Hayes, 282 

Head, 45, 261, 866 

Hebra, 376, 382 

Heer, 590 

Hegar, 11, 13, 21, 186, 281, 282, 293, 318, 

364, 602, 622, 698, 752, 753, 758, 760, 

762, 769, 770, 771, 773, 866 
Heil, 84 

Heinricius, 204, 206, 299 
Hellin, m 
Helme, 443 
Henke, 58 
Hennig, 805 
Henriet, 949 
Heoff, von, 816, 817 
Heppaer, 101, 102 
Herber, 525 
Herman, 33, 478, 679 
Hernandez, 713 
Hertz, 566 
Herzfeld, 698, 699 
Hewitt, 6, 286, 544, 585 
Hicks, 26, 470, 471 
Higginson, 640, 904 
Hildebrandt, 597 
Hippocrates, 585 
Hirschfeld, 382, 575 
His, 45 

Hochenegg, 698 

Hodge, 6, 419, 420, 521, 599, 870 
Hofmeier, 200, 201, 622, 701, 714, 720, 

721, 731 
Hollander, 74, 75 
Homans, 68 

Huguier, 5, 528, 538, 557 
Hunter, 8, 873 
Hiiter, 72, 378 

Illich, 798 
Imlach, 537 
Immerwahr, 207 
Israel, 798 

Jackson, 359 

Jacobs, 519, 621, 628 

Jacquemier, 577 

Jagoe, 341 

Jani, 794 

Janvrin, 825, 826 

Jeaffreson, 873 

Jessett, 295, 596, 874 

Jessop, 469 

Jobert, 779 

Jonas, 587 

Jones, 347 

Jones, Dixon (C), 825, 826 

Jones, Dixon (M.), 805, 843 

Jones, M'Naughton, 282 

Jones, Sydney, 880, 881, 884, 889 

Junker, 273 

Jusserand, Nove, 736, 737, 740 

3 Q 



962 



SYSTEM OF GYNECOLOGY 



Kahlden, von, 724 

Kaltenbach, 293, 622, 694, 712, 773, 804, 

813, 814, 816, 817 
Kammerer, 359 
Keating, 800 
Kehrer, 359 
Keiller, 487 
Keith, 10, 12, 14, 16, 342, 598, 616, 620, 

622, 626, 643, 873, 884, 885, 886, 889, 

892, 908 
Keith, Skene, 480 
Kelly, 55, 432, 625, 894 
Kemarski, 917 
Kennedy, 384 
Keppler, 69 
Key, 642 
Kilian, 443 
King, 873 
Kiorisch, 5 
Kiwisch, 920 

Klebs, 73, 100, 101, 444, 564, 650, 843, 846 
Klein, 739 

Kiob, 210, 445, 562, 592, 843, 846, 913 
Klotz, 198 
Kobelt, 70, 72 
Koch, 30 
Koeberle, 8, 10, 614, 620, 622, 628, 638, 

642 
Kolaczek, 841 
Kolliker, 443 
Konig, 4 

Kossmann, 69, 799, 805 
Kraske, 698 
Kroner, 919 
Krag, 627 

Krukenberg, 693, 713, 720, 946, 947 
Kiichenmeister, 291, 292, 365 
Kundrat, 27 
Kussmaul, 73 
Kustner, 191, 200, 204, 649, 921 

Lachapelle, 435 

Lacroix, 736, 737, 740 

Lallemand, 17 

Lamballe, 17 

Landau, 519, 652, 692, 694, 728, 732, 780, 

813, 817, 825, 826 
Landerer, 732, 733, 841, 842 
Lane, 877 
Langenbeck, 700 
Langhans, 736 
Langier, 525, 936 
Lantos, 209 
Lebert, 21 

Lee, 5, 189, 586, 592 
Lefort, 73, 89, 757, 759, 760 
Lefour, 593, 595 
Leiter, 257. 258 
Lembert, 899, 900 
Leopold, 27, 48, 472, 519, 589, 592, 596, 

634, 653, 818, 843 
Lepage, 434 



Lewers, 281, 488 

Lever, 22 

Lindsay, 105 

Lisfranc, 5, 586, 918 

Lister, 2, 10, 30, 622, 631, 873, 884 

Lockwood, 252 

Locock, 293 

Lohlein, 739 

Lucas, 342 

Luschka, 443 

Lusk, 346, 593 

Luther, 374 

M'Clintock, 525, 526, 547, 550, 563 

M'Dowell, 7, 8, 873 

Mackenrodt, 478, 692, 764, 765 

Madge, 525, 544, 547 

Mainert, 624 

Maisonneuve, 293 

Makins, 487 

Malassez, 846 

Malcolm, 252 

Malgaigne, 525 

Malherbe, 474 

Mallet, 583 

Mangiagalli, 79, 694, 695, 696, 720 

Marchand, 71, 736, 737, 843, 846 

Marckwald, 769, 770 

Marconnat, 389 

Marey, 564 

Martin, 12, 20, 57, 75, 76, 78, 79, 192, 292, 

384, 413, 438, 439, 472, 519, 621, 752, 

753, 760, 761, 762, 768, 771, 794, 795, 

806, 812, 821, 841, 909 
Martin, C, 106 
May, 342 
Mayor, 443 

Meadows, 292, 525, 533, 556, 559 
Meredith, 858 
Merge, 207, 738, 794 
Meyer, 102 
Michaelis, 639 
Minot, 118, 126 
Mitchell, Weir, 213, 228, 229 
Molitor, 342 
Mollinetti, 929 
Moostakov, 105 
Morand, 873 
More Madden, 276, 290 
Morgagni, 49, 64, 72, 87 
Mott, 445 
Muller, 84, 342, 390, 593, 630, 656, 657, 

658, 681 
Munde, 209, 293 
Munster, 795 
Muret, 461 

Murray, Milne, 365, 598, 600 
Museux, 919, 920 

Nagel, 60, 837 

Nelaton, 293, 525, 526, 556, 557, 600, 880, 
881 



LIST OF AUTHORITIES 



963 



Netter, 798 

Neudorfer, 931 

Neugebauer, 263, 274, 437, 438, 779, 781 

Newnham, 916 

Nikiforoff, 819 

Noble, 460 

Noggerath, 373. 919 

Nonat, 293, 528 

Nordau, Max, 223 

Nunn, 942 

OlSANDER, 936 

Olshausen, 67, 203, 204, 207, 252, 293, 
525, 539, 606, 690, 712, 838, 840, 842, 
844, 815, 846, 864, 866 

Orthmann, 384, 794, 795, 812 

Ott, de, 604 

Paget, 12, 21, 585, 934 

Palmer, 197, 210, 288, 289 

Paquelin, 266, 291, 609, 627, 705, 706, 

731, 762 
Par^, 17 
Paroiia, 802 

Parry, 463, 464, 478, 479 
Pasteur, 30 
Paul, 22 

P^an, 106, 517, 518, 604, 621, 622, 692, 820 
Pearson, 290 
Peaslee, 282, 292 
Penrose, 84, 794 
Petit, 929 

Pfannenstiel, 207, 714, 725, 726 
Pfluger, 66, 370 
Phillips, 105, 281, 282, 536 
Pick, 725, 726 
Picot, Qh^, 659 
Playfair, 206, 263, 264, 285, 356, 541, 

551, 631 
Pogg, 525 
Poirier, 42, 43 
Pole, 79 

Polk, 3, 488, 625, 627, 634 
Poncet, 542, 545, 552 
Popoff, 72 
Porak, 276, 577 
Porritt, 377 

Porro, 595, 596, 634, 637, 712 
Porter, 825 
Pott, 932 
Pozzi, 34, 84, 97, 99, 101, 104, 191, 194, 

212, 292, 341, 345, 526, 534, 546, 557, 

559, 577, 693, 746, 779, 908, 909 
Preuschen, v., 390 
Priestley, 1, 210, 288, 289, 292, 370, 374, 

552 
Prochownik, 201, 218, 341, 420, 800 
Prost, 528 
Puech, 67, 90, 525, 534 

Quisling, 84 

Rainey, 240 



Rauschning, 92 

Reamier, 700 

Recamier, 5, 21, 292, 293, 294, 524 

Recklinghausen, v., 806, 814, 816, 824 

Reeve, 914 

Regnier, 559 

Reid, 289, 290 

R^my, 84 

Renaud, 812 

Retzius, 51, 943 

Reverdin, 290 

Reymond, 309, 801 

Reynolds, 210, 552 

Rhein, 589 

Rheinstein, 813, 817 

Richard, 69 

Richelot, 519, 604, 621, 628, 633, 692, 694, 

695 
Rieux, 588 
Rindfleisch, 607, 846 
Ritchie, 802 
Rivington, 946 
Robert, 528, 548 
Robertson, 342 
Robin, 443 
Rokitansky, 21, 101, 210, 700, 803, 837, 

843, 846, 913 
Roser, 189 
Rouget, 525, 527 

Routh, 204, 295, 590, 591, 597, 747, 813, 816 
Routh, C. H. F., 281, 286, 293 
Routier, 559, 821, 822 
Roux, 17 
Rowlett, 342 
Ruedinger, 37 
Ruge, 20, 79, 189, 196, 197, 198, 203, 204, 

205, 650, 651, 652, 679, 680, 731, 732 
Ruppolt, 69 
Ruysch, 525 

Saint-Hilaire, 73 

Sajous, 913 

Sale, 476 

Sanger, 73, 373, 374, 443, 595, 634, 636, 

692, 712, 734, 735, 736, 801, 802, 805, 

806, 812, 813, 814, 816, 817, 818, 820, 

824, 825, 826 
Savage, 292, 599 
Scanzoni, 214, 293, 379, 525, 534, 538, 

563, 812, 924 
Schaffer, 84, 375, 488 
Schatz, 432 
Schauta, 699 
Schleich, 272 
Schlesinger, 4 
Schmidt, 342, 731 
Sclmeevocht, 384 
Schramm, 786, 795 
Schroeder, 12, 13, 76, 201, 202, 210, 292, 

293, 382, 534, 535, 538, 544, 563, 582, 

584, 595, 606, 622, 628, 651, 656, 701, 

713, 720, 724, 771, 807, 812 



964 



SYSTEM OF GYNECOLOGY 



Schuchardt, 391 

Schultz, 707 

Schiiltze, 199, 279, 420, 522, 841, 917, 918 

Schwartz, 800 

Segond, 517, 519 

Semon, 605, 607 

Senger, 814, 824, 825, 826 

Sequeira, 440 

Seyfert, 525 

Shattock, 818, 819, 844 

Sheild, 265 

Shucking, 763 

Siebold, v., 29 

Silcock, 793, 794 

Simon, 17, 293, 752, 753, 770, 773, 777, 
778, 779, 781 

Simpson, A. R., 597, 769, 771, 850, 915 

Simpson, Sir J. Y., 5, 193, 200, 201, 211, 
216, 274, 276, 290, 292, 330, 348, 362, 
365, 384, 447, 449, 450, 525, 528, 530, 
544, 550, 552, 558, 559, 594, 600, 656, 
800, 920 

Sims, Marion, 17, 55, 56, 262, 264, 274, 
277, 283, 288, 292, 293, 362, 364, 387, 
390, 599, 748, 753, 755, 757, 758, 761, 
763, 764, 765, 766, 767, 768, 769, 771, 
773, 774, 776, 777, 778, 779, 919, 920 

Sinclair, 12, 696 

Sin^ty, de, 82, 204, 205, 214, 215, 437, 846 

Sippel, 68, 909 

Skene, 62, 68, 74, 75, 432, 577, 928 

Skoldberg, 201 

Sloan, 276 

Smart, 340 

Smith, 342 

Smith, Albert, 420 

Smith, Greig, 628, 633, 634, 712 

Smith, Heywood, 282, 342 

Smith, Tyler, 5, 8, 28, 29, 188, 189, 920, 
922 

Smyly, 820 

Sonnenburg, 931 

Sorel, 370 

Spaeth, 800 

Spamer, 310 

Spiegelberg, 199, 589, 594, 682, 725, 844, 
925 

Steffich, 844 

Stephenson, 3 

Stevenson, 480 

Stewart, Sir Grainger, 71, 798 

Stoltz, 550, 756, 761, 762 

Storer, 639 

Stratz, 585 

Strauch, v., 559 

Strong, 95 

Suppinger, 85 

Susserot, 563, 593 

Sutton, Bland, 15, 16, 50, 62, 67, 70, 471, 
532, 562, 784, 793, 800, 804, 805, 806, 
810, 811, 839, 840, 841, 844, 846, 871 

Svensson, 913 



Tait, Lawson, 11, 12, 14, 16, 68, 105, 
192, 252, 290, 328, 464, 471, 478, 479, 
527, 531, 557, 591, 601, 873, 877, 878, 
883, 889, 893 

Tardieu, 105, 535 

Tarnowsky, 374 

Tate, 920 

Taylor, 462, 469, 522, 914 

Teale, 284 

Terrier, 694 

Theilhaber, 711, 712, 713 

Thiersch, 19, 653, 735 

Thiry, 922 

Thomas, Gaillard, 23, 197, 201, 293, 295, 
420, 557, 917, 920, 921, 922 

Thompson, Sir Henry, 942 

Thomson, 113, 269 

Thornton, Knowsley, 9, 11, 480, 532, 
622, 638, 678, 817, 841, 848, 880 

Tilt, 6, 525 

Tinns, 576 

Tourneaux, 96 

Trelat, 286 

Trendelenburg, 515, 874, 904, 906, 908, 
931 

Treub, 802 

Treves, 252, 498 

Trousseau, 293, 533, 536 

Tuckwell, 525, 538 

Tuffier, 818, 932, 934, 943, 947 

Turner, 585 

Tyson, 942 

Underhill, 605, 606 

Veit, 20, 21, 189, 196, 197, 203, 204, 374, 

387, 535, 650, 651, 652, 679, 680, 731, 

732, 817 
Velitz, v., 840 
Velpeau, 6, 17, 417, 604 
Verneuil, 528, 809 
Viatto, 382 
Vidal, 780 
Vigues, 525, 531 
Virchow, 19, 21, 39, 366, 485, 525, 535, 

576, 591, 650, 724, 725, 826, 846 
Voelcker, 821, 822 
Voison, 525, 526, 527, 529, 531, 532, 533, 

534, 536, 537, 539, 540, 542, 545, 546, 

547, 549, 556 
Volkneaux, 294 
Vulliet, 274, 276, 707 

Wagner, 607, 656 

Waldeyer, 19, 49, 52, 60, 650, 653, 839, 

846 
Wallent, 341 
Walsham, 947 
Walter, 477, 805, 810 
Warnek, 810, 819 
Wathen, 290 
Watteville, de, 33 



LIST OF AUTHORITIES 



965 



Watts, 920 

Webb, 765 

Weber, 256 

Weber, F., 552, 592 

Webster, Clarence, 464 

Weichselbaum, 786 

Weigert, 725 

Wells, Sir Spencer, 8, 9, 10, 91, 532, 616, 

637, 642, 656, 748, 749, 751, 758, 761, 

774, 79'.), 806, 807, 817, 878, 877, 878, 

879, 880, 881, 883, 884, 889 
AVertheim, 863, 865, 866 
West, 5, 189, 525, 536, 542, 544, 558, 563, 

936 
Westermark, 820 
Weston, 305 
White, 20, 922 
Williams, Sir John, 2, 7, 19, 20, 26, 27, 

361, 364, 444, 480, 552, 648, 652, 670, 

674, 678, 701, 702, 730, 731, 812 
Williams, J. D., 66, 69, 70, 71, 72 
Williams, Whitridge, 724, 788, 794, 795, 

799, 805, 839, 846, 865, 866 
Willius, 873 



Wilmont, 946 

Wilson, 342, 476 

Wiltshire, 28 

Winckel, 65, 66, 71, 206, 388, 534, 562, 

563, 593, 658, 660, 679, 683, 684, 699, 

729, 869 
Winter, 189, 207, 696, 697, 701, 702 
Winternitz, 780 
Woodhead, Sims, 353 
Worrall, 477 
Wright, 256, 356 
Wyder, 27, 29, 203, 204, 205, 570 
Wylie, 366 
Wynter, 820, 821, 822 

Zedel, 821 
Zemann, 798 
Ziegler, 731 
Zinnis, 67 
Zuccarelli, 103 
Zuckerkandl, 698 
Zwanck, 408 

Zweifel, 559, 621, 627, 694, 804, 817, 
820 



INDEX 



Abdomen, examination of, 171 
Abdominal tumour, recognition of, 854 
Abnormalities causing disease of the 

genital organs in women, 112 
Accidental and operative causes of dis- 
eases of the genital organs in women, 
147 
Actinomycosis of the Fallopian tube, 798 
Acute inflammation of ovarian tumours, 

849 
Adenoma malignum, 729 
Adenoma (simple) of uterus, 605 
Alexander- Adams operation, 411 
Amenorrhoea, 27, 343 ; primary and per- 
manent, 343 ; secondary, 344 ; symp- 
toms of, 347 ; treatment of, 347 
Anaesthesia in gynsecology, 272 
Anatomy of the female pelvic organs, 31 
Anatomy of female pelvic organs, recent 

developments in, 2 
Anteflexions of the uterus, see Antror- 

sions of the uterus. 
Anteversions of the uterus, see Antror- 

sions of the uterus 
Antiseptics in gynaecology, 267 
Antrorsions of the uterus, 420 ; causes 
and complications of, 421 ; diagnosis 
of, 422 ; symptoms of, 421 ; treatment 
of, 423 
Aphthous vulvitis, 377 
Appendages, uterine removal of, 904 
Armamentarium, electrical, 300 
Ascent of the uterus, 394 
Atrophy and hypertrophy of the Fal- 
lopian tubes, 783 

Balneo-therapeutics in gynsecology, 
255 

Bladder, anatomy of, 37 ; diseases of, 
928; cystitis (acute), 936, (chronic), 
940 ; displacement of, 928 ; ectopian 
vesicae, 930 ; functional diseases of, 
932 ; foreign bodies in, 949 ; rupture 
of, 946 ; stone in, 956 ; tubercular 
disease of, 942 ; tumours of, 951 ; 
vesico-vaginal fistula, 948 



Bloodletting in gynaecology, 265 

Broad ligament, cysts of, 845 

Broad ligaments, malformations of, 73 

CiESAREAN section, 634 

Calculus vesicae, see Stone in the bladder, 
956 

Cancer of cervix, 670 

Cancer of genital organs, etiology of, 133, 
643 

Cancer of the Fallopian tubes, 812 ; 
several considerations of, 823 ; treat- 
ment of, 823 

Cancer of body of uterus, 713 ; diagnosis 
of, 718 ; etiology of, 715 ; pathological 
anatomy of, 713; prognosis of, 720; 
symptoms of, 715; treatment of, 721 

Cancer of the ovary, 844 

Cancer of vagina, 391 

Carcinoma uteri, 181, 643 

Catarrh of cervix, see Cervical catarrh 

Cavernous angioma of uterus, 591 

Cervical catarrh, 195 ; clinical history 
and symptoms of, 195 ; diagnosis of, 
198 ; pathology in relation to physical 
signs, 196, treatment of, 199 

Cervical deformities, operation for, 769 

Cervicitis, etiology, 117 

Cervico- vaginal fistula, 441 

Cervix, circular amputation of (Hegar), 
769 ; fibromyoma of, 582 ; infravaginal 
hypertrophy of, 763 ; Marckwald's 
operation, 770; Sims' conoidal incision, 
769 ; lacerations of, 426 ; operation 
for laceration of, 765 ; supravaginal 
amputation of, 701 ; supravaginal 
hypertrophy of, 763 

Child-bearing, influence of fibromyoma 
on, 592 

Chronic pelvic cellulitis, 497 

Cirrhosis of the ovary, 864 

Clitoris and labia, malformations of, 96 

Colpitis, 385 

Colpitis mycotica, 388 

Colpoperineorrhaphy, A. Martin's 
method, 761 



967 



968 



SYSTEM OF GYNECOLOGY 



Colporrhaphy, 410, 757 

Colpotomy, 420, 522 

Complete abdominal hysterectomy, 626 

Complications of ovarian tumour, 848 

Condyloma of vulva, 381 

Congenital defects of development as a 

cause of disease of the female genital 

organs, 112 
Connective tissue of pelvis, anatomy of, 

38 
Conservative operations on the ovaries 

and tubes, 909 
Contagious diseases as causes of disease 

of the genital organs in women, 142 
Continuous current, mode of action, 315 
Curetting of uterus, 292, 355 
Current regulator in electrical treatment, 

303 
Cystic corpora lutea, 837 
Cystitis, acute, 936 ; chronic, 940 
Cystocele (Stoltz operation), 761 
Cystoma, proliferating, 838 
Cysts of tlie broad ligaments, 845 
Cysts of the Fallopian tube, 801 

Deciduoma malignum, 734 ; course and 
symptoms of, 737 ; diagnosis of, 740 ; 
pathological anatomy of, 736 ; prog- 
nosis of, 741 ; treatment of, 741 

Deciduoma malignum of the Fallopian 
tubes, 826 

Del^pine's, Professor, description of 
methods of microscopical examination 
of uterine tissues, 681 

Dermoid growths, ovariotomy for, 894 

Dermoid structures in ovarian cysts, 840 

Dermoid tumours of the Fallopian tube, 
802 

Dermoid tumour of ovary, etiology of, 126 

Descent of the uterus, 395 ; causes of, 
397 ; complications of, 401 ; degrees 
of, 395 ; pathological anatomy of, 396 ; 
physical diagnosis of, 402 ; prognosis 
of, 404 ; symptoms of, 402 ; treatment 
of, 404 

Diagnosis of chronic inversion of the 
uterus, 915 

Diagnosis in gynsecology, 151 ; additional 
means of examination, 186 ; examina- 
tion of the abdomen, 171 ; examina- 
tion by the vagina, 177 ; history of 
the patient, 151 ; history of present 
illness, 160 ; menstrual history, 153 ; 
obstetric history, 158 ; examination 
by means of sound, 185; previous ill- 
nesses, 160 

Diet, etiology of disease resulting from 
improper, 140 

Diffuse pelvic suppuration, 492 

Dilatation of the uterus in gynaecology, 
276 

Dilatation, rapid, of uterus, 281 



Diphtheritic vaginitis, 389 
Displacement of bladder, 928 
Displacements of the uterus, 393 
Dysmenorrhoea, 28, 358 ; etiology of, 
117 ; from defective development and 
obstruction, 361 ; intermenstrual, 369; 
membranous, 28, 366 ; spasmodic and 
inflammatory, 362 ; and sterility, 359 ; 
symptoms of, 363 ; treatment of, 364 ; 
varieties of, 360 

EcTOPioN vesicae, 930 

Eczematous vulvitis, 576 

Education of girls at and about the 
period of puberty, 220 

Education of girls, etiology of disease 
resulting from, 134 

Electrical treatment in diseases of 
women, 13, 300 

Electrical treatment of fibromyoma, 14, 
324, 597 

Electricity, mode of application in gynae- 
cology, 318 ; therapeutic application 
of, 317 ; armamentarium in, 300 

Elephantiasis vulvae, 382 

Elytritis, 385 

Elytroperineorrhaphy, vide Colpoperi- 
neorrhaphy, 760 

Elytroplasty, 779 

Elytrorrhaphy, 420 

Elytrorrhaphy, vide Colporrhaphy, 757 

Emphysematous vaginitis, 388 

Endometritis, chronic, 203 ; clinical 
history and symptoms of, 203 ; diag- 
nosis of, 203 ; etiology of, 122 ; pa- 
thology of, in relation to physical 
signs, 204 ; relation of micro-organ- 
isms to, 206 ; treatment of, 209 ; treat- 
ment of, by electricity, 320 

Endometritis-villous, 352 

Episio-perineorrhaphy, 757 

Epispadias in woman, 95 

Epithelioma portionis vaginalis uteri, 
646 ; causes of death from, 668 ; diag- 
nosis of, 673 ; duration of the disease, 
669 ; etiology of, 133, 655 ; palliative 
operations for, 703 ; pathological anat- 
omy of epithelioma of uterus, (546 ; 
pregnancy a complication of, 710; 
prognosis of, 685 ; recurrence after 
operation, 696 ; seat of origin of 
growth, 651 ; symptoms and clinical 
course of, 661 ; treatment of, 686 

Erysipelas vulvae, 378 

Etiology of the diseases of the female 
genital organs, 112 

Exfoliative vaginitis, 389 

Extirpation of uterus, operation for, 
686 ; Freund's operation for, 700; 
operations for partial, 701 ; recurrence 
after operation for, 696 ; results of, 
693 ; sacral method of, 698 



INDEX 



969 



Extraperitoneal haematocele, 530 
Extra-uterine dysmenorrhoea, 367 
Extra-uterine gestation, 451, see Tubal 
pregnancy 

Fallopian^ tubes, anatomy of, 48 ; acti- 
nomycosis of, 798 ; atrophy and 
hypertrophy of, 783 ; calcuhis simu- 
lating tumour of, 799 ; cancer of, 812 ; 
cysts of, 801 ; deciduoma malignum 
of, 826 ; dermoid tumours of, 802 ; 
diseases of the, 782 ; fibroma and 
enchondroma of, 798 ; hydatid disease 
of, 797 ; inflammation of, 784 ; injuries 
of, 782 ; lipoma of, 802 ; malformations 
of, 69 ; myoma of, 799 ; papilloma of, 
803 ; sarcoma of, 824 ; tuberculosis of, 
793 

Female pelvic organs, anatomy of, 31 

Fibrinous-polypus, 609 

Fibro-adenoma of uterus, 606 

Fibro-cystic tumours, 586 

Fibroid tumour of uterus, see Fibro- 
myoma 

Fibroid of vagina, 390 ; vulva, 384 

Fibroma and enchondroma of the Fallo- 
pian tube, 798 

Fibromyoma of uterus, 561, 612 ; absorp- 
tion and atrophy of, 687, 595 ; calci- 
fication of, 585 ; cervix in, 582 ; cystic 
changes in, 586 ; diagnosis of, 574 ; 
diagnosis of subperitoneal, 578; elec- 
trical treatment of, 324, 597 ; growth 
and course of, 576 ; haemorrhages 
from, 572 ; hsemorrhage, source of 
572 ; influence of, in child-bearing, 
592 ; influence of pregnancy on, 592 
influence of sterility, 564 ; interstitial 
580 ; malignant degeneration of, 586 
medical treatment of, 596 ; pain con- 
nected with, 575 ; pathological anat- 
omy of, 564 ; pregnancy connected 
with, 592 ; pregnancy, treatment of, 
connected with, 595 ; secondary 
changes in, 585 ; sloughing of, 586 ; 
submucous variety of, 576 ; subperi- 
toneal, 575 ; symptoms of subperito- 
neal, 577 ; surgical treatment of, 599 ; 
symptoms of, 573 

Fibrous-papilloma of uterus, 607 

Fistulge, vaginal, 436 

Fistulous openings, operation for repair 
of, 771 

Flap-splitting or dklouhlement^ 775 ; f fe- 
cal fistulge, 782 

Forceps delivery as a cause of laceration, 
426 

Foreign bodies in the bladder, 949 ; 
symptoms of, 950 ; treatment of, 950 

Foreign bodies in vagina, 391 

Freund's operation for total extirpation 
of uterus, 700 



Functional disease of the bladder, 932 
Functional disease of distant organs 
(secondary) in gynsecology, 225 

Galvanometer in electrical treatment, 

304 
Genital organs of women, development 
of, 27, 64 ; etiology of diseases of, 
112 ; hypersemia of, 372 ; inflamma- 
tion of, 373 ; malformations of, 63 
Genital organs, external, diseases of, 372 
Gonorrhoea, etiology of disease resulting 

from, 143 
Grape-like sarcoma of uterus, 725 
Gravid uterus, operations on, 633 
Gynsecological therapeutics, 249 ; bal- 
neo-therapeutics in, 255 ; bloodletting 
in, 265 ; drugs in, 252 ; general hy- 
giene in, 250 ; local therapeutical 
measures in, 256 ; operations in gynae- 
cology, 267 ; rest in, 251 ; antiseptics 
in, 267 
Gynaecology, development of modern, 1 ; 
anatomy, 2 ; disorders of menstrua- 
tion, 27 ; extra-uterine pregnancy, 
14 ; inversio uteri, 29 ; malignant dis- 
eases, 19 ; pathological and clinical 
aspects, 5 ; pelvic inflammations, 22 ; 
surgery in, 7 ; vesico-vaginal fistulae, 17 

H.EMATOCELE, pelvic, 524 ; causes of, 
538 ; definition and synonym of, 524 ; 
diagnosis of, 547 ; extraperitoneal, 
530 ; intraperitoneal, 529 ; pathologi- 
cal anatomy of, 536 ; pathology of, 
525 ; prognosis of, 551 ; sources of 
haemorrhage, 581 ; symptoms and 
progress of, 540 ; treatment of, 553 

Haematoma, see Haematocele 

Haematoma of the ovary, 868 

Haematoma vulvae, 381 

Haemorrhage, from fibro-myomata, 572 

Heredity as a cause of disease of the 
female genital organs, 112 

Hermaphroditism, 100 

Hernia of ovary, 871 ; symptoms of, 871 ; 
diagnosis of, 872 

Hernia of vulva, 379 

Herpes vulvae, 376 

Hydatids of the ovary, 841 

Hydatids, etiology of disease resulting 
from, 147 

Hydrops folliculorum, 837 

Hymen, the, 178; anatomy of, 34 ; cause 
of imperforate, 116 ; malformations of, 
97 

Hypospadias in woman, 95 

Hysterectomy, 611 ; after treatment, 
639 ; complete abdominal hysterec- 
tomy, 626 ; for fibromyoma, 12, 604 ; 
for intractable inversion, 633 ; for pro- 
cidentia, 630 ; supravaginal extraperi- 



970 



SYSTEM OF GYNECOLOGY 



toneal, 614 ; intraperitoneal, 618 ; 
Baer's operation, 622 ; Byford's opera- 
tion, 624 ; Dudley and Goffe's opera- 
tion, 623 ; Eastman and Chrobak's 
operation, 624 ; Polk's operation, 625 

Hystero-epilepsy, oophorectomy in, 230 

Hysteroma, see Fibromyoma 

Hysteropexy, 411, 763 

Idiopathic hsemorrhage, 353 

Incarceration of ovarian tumours in the 
pelvis, 851 

Incontinence of urine, 934 

Inflammation of the Fallopian tubes, 784 

Inflammation of the ovaries, 861 

Inflammation of the uterus, 187 

Injuries to bladder, 946 

Injuries of the Fallopian tubes, 782 

Insanity in relation to gynaecology, 229 

Intermenstrual dysmenorrhoea, 369 

Interstitial fibromyoma, 580 

Intraligamentous tumours, ovariotomy 
for, 895 

Intraperitoneal hsematocele, 529 

Inversio uteri, 29 

Inversion, chronic, of the uterus, 911 ; 
anatomy and pathology of, 912 ; course 
and results of, 917 ; diagnosis of, 915 ; 
etiology of, 914 ; mechanism of pro- 
duction, 913 ; symptoms of, 915 ; treat- 
ment of, 918 

Inversion of uterus, hysterectomy for, 633 

Involution of uterus, 442 

KOLPO-HYSTERECTOMT, 631 

Kolpokleisis, 779 
Kraurosis vulvae, 584 

Labia majora, anatomy of, 34 
Labia minora, anatomy of, 34 
Laceration of cervix, etiology of, 119; 
immediate repair of, 426 ; results of, 
427 
Lacerations of pelvic floor proper, 746 
Laparotomy in pelvic peritonitis, 514 
Lateral deviations of the uterus, 423 
Lefort's operation, 759 
Leioma, 562 

Lipoma of the Fallopian tube, 802 
Local therapeutical measures in gynae- 
cology, 256 
Lupus vulvae, 22, 382 
Lymphatics of pelvis, anatomy of, 44 

Malignant disease of uterus, 643 
Malignant diseases of vulva, 383 
Malignant growths in ovarian cysts, 841 
Marriage, etiology of disease following, 

141 
Mechanism of production of chronic in- 
version of the uterus, 913 



Membranous dysmenorrhoea, 28, 366 

Menorrhagia and metrorrhagia, 349 ; 
during active, fertile life, 351 ; during 
menopause, 354 ; during puberty, 351 ; 
symptoms of, 354 ; treatment of, 354 ; 
idiopathic, 353 

Menstruation, disorders of, 26, 339; eti- 
ology of disorders, 135 ; its relation to 
the education of girls, 221 ; premature, 
339 ; protracted, 343 ; scanty, 348 ; 
vicarious, 347 

Mesometric gestation, 463 

Metritis and endometritis, acute, 202 ; 
chronic, 203 ; clinical history and 
symptoms of, 202 ; diagnosis of, 207 ; 
pathology of, in relation to physical 
signs, 204 ; treatment of, 209 

Micro-organisms in the etiology of disease 
of the female genital organs, 206 

Myoma of the Fallopian tube, 799 

Myoma of uterus, etiology of, 131 

Naturae progress of ovarian tumours, 
847 

Nerves of pelvis, anatomy of, 44 

Nervous system in relation to gynaecol- 
ogy, 220 

Neurasthenia in relation to gynaecology, 
227 

Neuroses, oophorectomy and, 230 

Noma pudendi, 377 

Nutrition, defective, in gynaecology, 227 

Oophorectomy, 11, 904 ; in functional 
neuroses, 230 ; in inflamed and ad- 
herent appendages, 906; for fibro- 
myoma, 906 

Oophoritis, 862 ; diagnosis of, 868 ; 
symptoms of, 866 ; treatment of, 868 

Oophoritis serosa, 864 ; tubercular, 865 

Operations in gynaecology, 267 

Operative causes of disease of female 
genital organs, 147 

Ovarian artery, anatomy of, 49 

Ovarian cystoma, etiology of, 127 

Ovarian pregnancy, 471 

Ovarian tumours, 836; acute inflamma- 
tion of, 849; complications of, 848; 
diagnosis of, 852 ; etiology of, 845 ; 
incarceration of, in the pelvis, 851 ; 
natural progress of, 847 ; pregnancy 
and labour complicated by, 851 ; 
rupture of, 851 ; strangulation of 
the pedicle in, 860 ; torsion of the 
pedicle in, 849 

Ovaries, anatomy of, 49 ; carcinoma of, 
844 ; cirrhosis of, 864 ; haematoma of, 
868 ; hernia of, 871 ; hydatids of, 841 ; 
malformation of, 65 ; oedema of, 864 ; 
prolapse of, 869 ; removal of, and 
menstruation, 346; sarcoma of, 843; 
tubercle of, 865 ; tumour of, 836 



INDEX 



971 



Ovaries and tubes, removal of, for fibro- 
myoma, 628 

Ovariotomy, 7, 872 ; accidents and com- 
plications in, 897 ; adhesions in, 888 ; 
after treatment in, 900 ; arrangements 
for operation, 876 ; coverings of the 
patient in, 875 ; drainage in, 892 ; 
dressings in, 893 ; emptying and de- 
livering cyst in, 887 ; history of, 873 ; 
incomplete operations, 897 ; instru- 
ments used in, 877 ; irrigation in, 891 ; 
operating table in, 874 ; operating 
room in, 874 ; parietal incision in, 
886 ; pedicle, treatment of, in, 889 ; 
peritoneum, toilet of, in, 891 ; preg- 
nancy, ovariotomy in, 896 ; prepara- 
tion of patient for, 875 ; preparatory 
measures in, 873 ; sponges and sponge- 
cloths in, 876 ; suturing the parietal 
wound in, 893 

Ovary, solid tumours of, ovariotomy for, 
895 

Palliative operations for cancer of the 
uterus, 703 

Papilloma of the Fallopian tube, 803 

Papilloma of genital organs, etiology of, 
130 

Parametritis, see Pelvic cellulitis 

Parovarian cyst, etiology of, 127 

Parturition, morbid conditions resulting 
from, 425 

Pelvic abscess, 491 

Pelvic cellulitis, 487 ; anatomy of, 48f ; 
diagnosis of, 493 ; definition of, 487 ; 
etiology of, 88 ; frequency of, 489 ; 
pathological anatomy of, 489 ; physi- 
cal signs of, 490 ; prognosis of, 495 ; 
treatment of, 490 ; symptoms of, 
489 

Pelvic exudations, treatment of, by elec- 
tricity, 335 

Pelvic floor, anatomy of, 744 ; injuries 
of, 431 

Pelvic inflammation, 22, 485 

Pelvic organs, anatomy of, 31 ; develop- 
ment of, 57 

Pelvic peritonitis, 498; definition and 
nature, 498 ; diagnosis of, 509 ; etiology 
of, 498 ; pathological anatomy of, 503 ; 
physical signs of, 509 ; prognosis of, 
511 ; symptoms of, 506; treatment of, 
513 

Pelvis, dissectional anatomy of, 53 ; 
structural anatomy of, 55 ; surgical 
anatomy of, 56 

Perimetritis, see Pelvic peritonitis 

Perineorrhaphy, Alexander Duke's 
method, 754 ; A. Martin's method, 
753 ; Simon-Hegar operation, 752 

Perineum, anatomy of, 54 ; rupture of 
the, 433 ; complete rupture of, 745 ; 



partial rupture of, 745 ; plastic opera- 
tion for complete rupture of (peri- 
neorrhaphy), 747 

Perioophoritis, 498, 861 

Perisalpingitis, 498 

Peritoneum, anatomy of pelvic, 3, 50 

Peritonitis, etiology of, 144 

Peri-uterine phlegmon, see Pelvic cellu- 
litis 

Personal habits as causes of disease of 
the genital organs in v^'oman, 135 

Phlegmonous perivaginitis, 389 

Physical exercise in relation to the edu- 
cation of girls, 321 

Placental polypus, 609 

Plastic gynecological operations, 743 

Plastic operations for displacements of 
pelvic floor, 756 ; for pelvic floor 
lacerations, Emmet, 754 

Polypus uteri, 557 ; fibrinous, 609 ; for- 
mation of, 570; haemorrhage, source 
of, 573; intermittent. 571 ; inversion 
of uterus from, 571, 915; leucorrhcea 
connected with, 573; placental, 609; 
removal of, 603 ; sloughing of, 571, 586 

Porro's operation, 637 

Pregnancy as a complication of cancer 
of the uterus, 710; diagnosis of, 173; 
influence of, on fibromyoma, 592 ; 
ovariotomy in, 896 

Premature menstruation, 339 

Primary and permanent amenorrhcea, 
343 

Procidentia uteri, 395 

Procidentia, hysterectomy for, 630 

Prolapse of the ovary, 869 

Prolapse of uterus, 395 

Prolapse of urethral mucous membrane, 
762 

Protracted menstruation, 343 

Pruritus vulvae, 378 

Psammoma, 839 

Puberty, menorrhagia at time of, 351 

Purgatives in gynaecology, 252 

Pyosalpinx, 505, 789 ; etiology of, 122 

Recto-vagixal fistula, 442 

Rectum, anatomy of, 37 

Rest cure, the, in gynaecology, 228 

Rest in gynaecology, 251 

Retroflection, see Retrorsion 

Retrorsions of the uterus, 412 ; causes of, 
412; complications of, 414; diagnosis 
of, 416; prognosis of, 417; symptoms 
of, 414 ; treatment of, 417 

Retroversion of the uterus, see Retror- 
sion of the uterus 

Rheostats in electrical treatment, 303 

Round ligaments, malformation of, 73 

Rupture of the bladder, 946 

Rupture of cystic tumours of the ovary, 
851 



972 



SYSTEM OF GYNAECOLOGY 



Sacral method of total extirpation of 
uterus, 698 

Salpingitis, 784 

Salpiugo-oophorectomy, 904 

Sarcoma botryoides, 725 

Sarcoma of genital organs, etiology of, 
133 

Sarcoma of the Fallopian tubes, 824 

Sarcoma of the ovary, 843 

Sarcoma of uterus, 21, 722; diagnosis 
of, 728 ; pathological anatomy of, 723 ; 
prognosis of, 728 ; symptoms and 
courses, 726 ; treatment of, 729 

Sarcoma of vagina, 391 

Secondary amenorrhoea, 344 

Septic vulvitis, 377 

Serous perimetritis, 503 

Sexual appetite, causes of defective, in 
women, 135 

Sexual organs, excessive use of, as a 
cause of disease of the genital organs 
in women, 142 

Stenosis, treatment of, by electricity, 
317 

Sterility and dysmenorrhoea, 359 

Sterility, 231; acquired sterility, 235; 
contingent sterility, 235 ; acquired 
contingent sterility, 238 ; cases of ab- 
solute sterility, 233 ; conditions lead- 
ing to, 232 ; influence of fibromyoma 
on, 563 ; statistics of, 232 

Stone in the bladder, 956 ; symptoms, 
prognosis, treatment, 957 

Strangulation of the pedicle in ovarian 
tumours, 860 

Subinvolution, treatment of, by electri- 
city, 323 

Submucous fibromyoma, 567 

Subperitoneal fibromyoma, 575 

Subperitoneo-pelvic gestation, 463 

Superinvolation of the uterus, 447 

Supravaginal extirpation of cervix, 701 

Supravaginal hysterectomy, intraperi- 
toneal, 618 

Supravaginal hysterectomy, extraperi- 
toneal, 614 

Surgical anatomy of pelvis, remarks on, 
56 

Syphilis as a cause of disease of the 
genital organs in women, 142 

Tents, dilatation of uterus by, 276 

Therapeutical operations in gynsecology, 
274 

Thrombus vulvse, 381 

Tight-lacing, etiology of disease from, 
136 

Tonics in gynaecology, 253 

Torsion of the pedicle of ovarian tu- 
mours, 849 

Trachelorrhaphy, 765 

Tubal abortion, 458 



Tubal moles, 455 

Tubal pregnancy, 451 ; causes of, 125, 
451 ; changes in the tube in, 454 ; 
diagnosis of, 472 ; differential diag- 
nosis of, 476 ; the placenta and decidua 
in, 464 ; retention of the foetus in, 473 ; 
abortion in, 459 ; the mole in, 454 ; 
rupture in, 460 ; treatment of, 481 

Tubercle of the ovary, 865 

Tubercular disease of the bladder, 942 ; 
diagnosis of, 944 ; morbid anatomy of, 
943; prognosis of, 945 ; treatment of, 
945 

Tuberculosis, etiology of disease result- 
ing from, 146 

Tuberculosis of the Fallopian tubes, 793 ; 
pathology of, 795 ; symptoms and diag- 
nosis of, 796 ; treatment of, 797 

Tubo-uterine gestation, 470 

Tumours of the bladder, 951 ; pathologi- 
cal complications of, 953 ; symptom 
of, 953 ; diagnosis of, 954 ; prognosis 
of, 955 ; treatment of, 955 

Tumours of the ovary, 836 ; complica- 
tions of, 848 ; diagnosis of, 852 ; etiol- 
ogy of, 845 ; natural progress of, 847 

Tumours of the uterus, 131, 561, 612 

Uretero-vaginal fistula, 437, 780 

Ureters, anatomy of, 37 

Urethra, anatomy of, 36 ; diseases of, 
927 

Urethral caruncle, 928 

Urethrocele, 762 

Urinary fistula, 771 

Uterine artery, anatomy of, 41 

Uterine appendages, removal of, in fibro- 
myoma, 13, 601, 629 

Uterine dysmenorrhoea, 361 

Uterus, anatomy of, 45 ; adenoma of, 
605 ; antrorsions of, 420 ; ascent of, 
394 ; cancer of body of, 713 ; cancer 
of the cervix of, 670 ; and epithelioma 
portionis vaginalis of, 646 ; descent 
of, 395 ; fibro-adenoma of, 606 ; fibro- 
myoma of, 562, see Fibromyoma ; 
fibrous papilloma of, 607 ; inflamma- 
tion of, 187 ; involution of, 443 ; lateral 
deviations of, 423 ; malignant diseases 
of, 643; malformations of, 73; mor- 
cellation of, in pelvic peritonitis, 517 ; 
mucous growths of, 605 ; partial extir- 
pation of, 701 ; retrorsions of, 412 ; 
sarcoma of, 722 ; simple growths of, 
561 ; total extirpation of, 686 ; ventro- 
fixation of, 420 

Vagina, anatomy of the, 35 ; diseases 
of, 385 ; examination by the, 177 ; 
injuries of, resulting from parturition, 
427 : malformations of, 85 ; tumours 
of, 390 



INDEX 



973 



Vaginal fistula, 436 

Vaginal frsation, 763, vide Hysteropexy 
Vaginal hysterectomy in pelvic peri- 
tonitis, 517 
Vaginal urethrocele, 762 
Vaginismus, 389 
Vaginitis, 385 
Varicocele of vulva, 381 
Vascular growth of urethra, 928 
Veins of pelvis, anatomy of, 42 
Venereal diseases of vulva, 379 
Venous supply of uterus, anatomy of, 43 
Ventro-fixation of uterus, 411, 420 
Vesico-uterine fistula, 779 
Vesico-utero-vaginal fistula, 779 



Vesico-vaginal fistula, 17, 436, 772, 948 ; 
etiology, 948 ; symptoms, 948 ; diag- 
nosis, 948 ; treatment, 773 ; Bozeman's 
method, 778; Sims' method, 773; 
Simon's method, 777 

Vestibule, 34 

Vicarious menstruation, 347 

Villous endometritis, 352 

Vulva, diseases of, 373 ; malformations 
of, 93 ; pruritus of, 378 ; thrombus of, 
381 ; tumours of, 383 

Vulvitis, 373 



Weir Mitchell 

cology, 228 



treatment in gynae- 



THE END 



Works on Medical Science and 
Cognate Subjects, 



PUBLISHED BY 



THE MACMILLAN COMPANY. 



ANDERSON (J. W.). — Lectures on Medical Nursing. i6mo. 75 cents. 
Essentials of Physical Diagnosis of the Chest and Abdomen. 75 cents. 

" Dr. Anderson has written in a style as compact as possible, with a view to the economy of time, 
yet has satisfactorily covered his subject." — N". Y. Times. 

BALFOUR. — The Senile Heart. Its Symptoms, Sequelae, and Treatment. By 
George William Balfour, M.D. i2mo. Cloth. $1.50. 

"Cleverly written in a thoroughly interesting and practical style." — American Medico-Surgi- 
cal Bulletin. 

" A very clearly expressed and readable treatise upon a subject of great interest and importance. 
We can heartily commend this work as a valuable contribution to the literature of old age." — Medi- 
cal Record. 

BALLANCE (C. A.) and EDMUNDS (W.). — A Treatise on the Ligation 
of the Great Arteries in Continuity. With Illustrations. Royal 8vo. 
^4.00. 

" This book will become a classic. It is on a timely and important subject, and is the fruit of 
deep and thorough research." — Medical atid Surgical Journal. 

BARWELL (R.).— Lateral Curvature of the Spine, gi.75. 

BICKERTON (T. H.). — On Colour-blindness. Illustrated. Nature Series. 
{In the press.) 

BLYTH (A. W.). — A Manual of PubUc Health. 8vo. ^5.25. 
Lectures on Sanitary Law. 8vo. 32.50. 

BRODIE. — Dissections Illustrated. A Graphic Handbook for Students of 
Human Anatomy. By C. Gordon Brodie, F.R.C.S., Senior Demonstrator 
of Anatomy, Middlesex Hospital Medical School ; Assistant Surgeon, North- 
west London Hospital. With plates drawn and lithographed by Percy 
HiGHLEY. Complete in one volume. $9.00. 



WORKS ON THE MEDICAL SCIENCES 



Part I. The Upper Limb. With seventeen Coloured Plates, two-thirds 
natural size, and ten Diagrams. $2,00. 

" The plates are exceedingly well drawn and placed on the stone. . . . The explanatory letter- 
press is clear and concise." — The Lancet. 

" Of such high merit are the plates of this, the first volume, that the publication of the three 
remaining numbers of the series will be awaited with impatience by all students of anatomy." — The 
Hospital. 

" The scheme is admirably carried out and the plates most reliable. . . . We can confidently 
recommend the work." — Guj/'s Hospital Gazette. 

Part II. The Lower Limb. With twenty Coloured Plates and six Dia- 
grams. ^2.50. 
Part III. Head, Neck, and Thorax. With 20 Plates. ^2.50. 
Part IV. Abdomen. With 16 Plates, 13 Diagrams. $2.50. 

BRUNTON. — Works by T. Lauder Brunton, M.D., F.R.S. 

On Disorders of Digestion : their Consequences and Treatment. 8vo. $2.50. 
Pharmacology and Therapeutics; or, Medicine Past and Present. ^1.50. 
An Introduction to Modern Therapeutics. 8vo. ^1.50. 

BURDON-SANDERSON (J.). — Memoirs on the Physiology of Nerve, 
of Muscle, and of the Electrical Organ. Edited by J. Burdon- 
Sanderson, M.D., F.R.SS.L. & E. 8vo. ^5.25. 

CARRINGTON (R. E.). — A Manual of Dissections of the Human 
Body. Second Edition, revised and enlarged. ^2.50. 

CARTER (R. B.). — Eyesight : Good and Bad. Second Edition, enlarged. 
With Illustrations. 8vo. $1.00. 

CREIGHTON. — A History of Epidemics in Great Britain. By Charles 
Creighton, M.A., M.D., formerly Demonstrator of Anatomy in the Uni- 
versity of Cambridge. 8vo. 
Vol. I. From A.D. 664 to the Extinction of the Plague. $4.50. 
Vol. II. From the Extinction of the Plague to the Present Time. 
8vo. ^5.00. 

CROCKER. —Atlas of the Diseases of the Skin. In a Series of Illustra- 
tions (coloured) from Original Drawings, with Descriptive Letterpress. By H. 
Radcliffe Crocker, M.D., F.R.C.P., Physician, Skin Department, University 
College Hospital, London ; formerly Physician to the East London Hospital 
for Children ; Examiner in Medicine, Apothecaries' Hall, London. Superbly 
illustrated in colours. The plates (96 in number) represent fully 200 life-size 
figures, and are reproduced by chromo-lithography from the original water- 
colour drawings. Each fasciculus consists of six full-page plates, with descrip- 
tive letterpress. The letterpress not only describes the cases from which the 
drawings are taken, but also gives a general account of each disease, its 
differential diagnosis, and treatment. To be issued in 16 folio bi-monthly 
parts. Each part, ^6.00. Sold only on siibscription to the entire set. 

DOLAN (T. M.). — Pasteur and Rabies. By Thomas M. Dolan, M.D., 
F.R.C.S. i6mo. 50 cents. 

DOWNIE. — Clinical Manual for the Study of Diseases of the Throat. 

By JamEo Walker Downie, M.B. $2.50. 



AND CONNECTED SUBJECTS. 



ECCLES. — Sciatica. A Record of Clinical Observations on the Causes, Nature, 
and Treatment of Sixty-eight Cases. By A. Symons Eccles. $i.oo. 

" The generally accepted views touching the origin, symptoms, and treatment of sciatica, are 
lucidly presented in this brief record of personal observations. The author does not aim to furnish an 
elaborate monograph on the subject. -Asa clinical contribution to sciatica the little book will be read 
with interest." — Medical Record. 

The Practice of Massage : Its Physiological Effects and Therapeutic 
Uses. By A. Symons Eccles, M.B. Aberd., Member Royal College Sur- 
geons, England; Fellow Royal Medical and Chirurgical Society, London; 
Member Neurological Society, London; etc. 8vo. $2.50. 

FAYRER. — On the Preservation of Health in India. By Sir J. Fayrer, 
K.C.S.I., M.D., F.R.S. iSmo. 35 cents. 

FEARNLEY (W.). — A Course of Elementary Practical Histology. $2.00. 

FITZGERALD (C. E.). — Lectures on Physiology, Hygiene, etc. With 
Illustrations and Diagrams. 75 cents. 

FLUCKIGER (F. A.) and HANBURY (D.). — Pharmacographia. Second 
Edition, revised. 8vo. 35-00' 

FOSTER. —A Text-Book of Physiology. By Michael Foster, M.A., M.D., 
LL.D., F.R.S. , Professor of Physiology in the University of Cambridge, and 
Fellow of Trinity College, Cambridge. 8vo. With Illustrations. Sixth Edi- 
tion, largely revised. 
Part I. Blood ; the Tissues of Movement ; the Vascular Mechan- 
ism. S2.60. 
Part II. The Tissues of Chemical Action; Nutrition. $2.60. (/« 

the press.') 
Part III. The Central Nervous System. $1.75. 
Part IV. The Central Nervous System {^concluded) ; The Tissues 

and Mechanisms of Reproduction. 32.00. 
Part V. (Appendix) The Chemical Basis of the Animal Body. By 
A. Sheridan Lea, M.A., Sc.D., F.R.S. 31.75. 

" The present edition is more than largely revised. Much of it is re-written, and it is brought 
quite abreast with the latest wave of progress of physiological science. A chief merit of this work is 
its judicial temper, a strict sifting of fact from fiction, the discouragement of conclusions based on 
inadequate data, and small liking shown toward fanciful though fascinating hypotheses, and the 
avowal that to many questions, and some of foremost interest and moment, no satisfying answers can 
yet be given." — N'eiu England Medical yoitrnal. 

" It is in all respects an ideal text-book. It is only the physiologist, who has devoted time to the 
study of some branch of the great science, who can read between the lines of this wonderfully general- 
ized account, and can see upon what an intimate and extensive knowledge these generaHzations are 
founded. It is only the teacher who can appreciate the judicial balancing of evidence and the power 
of presenting the conclusions in such clear and lucid forms. But by every one the rare modesty of the 
author in keeping the element of self so entirely in the background must be appreciated. Reviewing 
this volume as a whole, we are justified in saying that it is the only thoroughly good text-book of 
physiology in the English language, and that it is probably the best text-book in any language." — 
Edinburgh Medical yoiimal. 

" From its first issue as a single octavo volume of moderate size, in 1876, it has so grown that 
each of the five Parts is, in this sixth edition, nearly as large as the entire original work. From the 
beginning it was regarded as a masterpiece, and at once took a prominent place among text-books of 
physiology. . . . If one seeks for the reason of the high estimate in which this work is held on both 
sides of the Atlantic, by the most advanced students as well as by general readers, it may be found in 
the beauty and simplicity of the style, in the lack of personal prejudice on the part of the author* in 



WORKS ON THE MEDICAL SCIENCES 



his thorough familiarity with the progress of physiological knowledge, and in the rare judgment with 
which purely hypothetical ideas and those founded on sufficient evidence are discriminated. The 
work is therefore a most admirable guide to physiological progress as well as general physiological 
knowledge." — The Nation. 

FOSTER. — Text-Book of Physiology. In one volume. By Michael 
Foster, M.A., M.D., etc., etc. Abridged and revised from the Sixth Edition 
of the Author's larger Work published in five octavo volumes. 8vo. Cloth, 
$5.00; Sheep, $5.50. 

This new Edition will contain all the Illustrations included in the larger work, and will be pub- 
lished in one octavo volume of about 1000 pages. It will contain all of the author's more important 
additions to the complete work, and be like the sixth edition of that copyrighted in this country. 

rOSTBR (M.) and BALFOUR (F. M.). — Practical Embryology. With 

Illustrations. ^2.60. 

" A book especially adapted to the needs of medical students, who will find in it all that is most 
essential for them to know in the elements of vertebrate embryology." — Academy. 

FOSTER (M.) and L ANGLE Y (J.N.). — A Course of Elementary Prac- 
tical Physiology. Fifth Edition, enlarged. ^2.00. 

"This work will prove of great value to the teacher of physiology, as an aid to the preparation 
of an eminently practical course of lectures and demonstrations of elementary experimental physi- 
ology. Its chief utility, however, will be to the intelligent student, who, armed with a dissecting case, 
a microscope, and the book, will be enabled to pass his summer vacation in a manner at once interest- 
ing and profitable." ■ — Medical Record. 

FOSTER (M.) and SHORE (L. E.). —Physiology for Beginners. i6mo. 
Illustrated. 75 cents. 

" It is a veritable multum in ^arvo, and will be fully appreciated by those for whom it is 
intended." — Ainerica7i Medico-Surgical Bulletin. 

" Nothing at once so scientific and so simple has appeared on the subject. It is unreservedly 
commended as a text-book for secondary schools." — The Educational Review. 

GALTON. — Healthy Hospitals. Observations on some points connected with 
Hospital Construction. With Illustrations. By Sir Douglas Galton, K.C.B., 
-F.R.S. ^2.75. 

" This is a valuable contribution to the literature of a most important subject. The eminence in 
engineering circles of Sir Douglas Galton would alone determine its merit. After a brief introduction 
into the origin of hospitals, he defines them as places ' not only for the reception and cure of the sick 
poor . . . but also as technical schools in which the medical student must learn his profession, and as 
experimental workshops in which the matured physician or surgeon carries on scientific research.' . . . 
While the subject-matter is largely technical, it is presented in a clear style, and its meaning is clear 
to any intelligent person. We commend Sir Douglas Gallon's book to all builders of hospitals." — 
Medical Record. 

GAM GEE. — A Text-book of the Physiological Chemistry of the Ani- 
mal Body. Including an Account of the Chemical Changes occurring in 
Disease. By Arthur Gamgee, M.D., F.R.S. 8vo. 
Vol. I. The Proteids. $4.50. 

Vol. II. The Physiological Chemistry of Digestion. With two chromo- 
lithographic Charts by Spillon and Wilkinson. ^4.50. 

GILLIES. — The Theory and Practice of Counter-irritation. By H. 
Cameron Gillies, M.D. 8vo. ^2.50. 

GOODFELLOW(J.).— The Dietetic Value of Bread. $1.50. 

GRESWELL (D. A.). — A Contribution to the Natural History of Scar- 
latina. 8vo. $2.50. 



AND CONNECTED SUBJECTS. 



GRIFFITHS (\Y, H.)- — Lessons on Prescriptions. i8mo. $i.oo. 
HAMILTON (D. J.). — A Systematic and Practical Test-book oi 
Pathology. 
Vol. I. Technical. General Pathological Processes. Diseases of 

Special Organs. 8vo. 36.25. 
Vol. II. Diseases of Special Organs {continued). Bacteriology, etc. 
2 Parts. 8vo. Each $5.00. 

*' This is beyond question the most complete work on Pathology in the English language to-day. 
The author has accomplished his laborious task most successfully. We cannot better criticise it than 
by saying it is beyond criticism." — Canada Medical Record. 

HAVILAND. — The Geographical Distribution of Disease in Great 
Britain, By Alfred Haviland. Second Edition. Svo. $4.50, 

HAWKINS (H. P.). — On Diseases of the Vermiform Appendix. With 
a consideration of the symptoms and treatment of the resulting forms of 
Peritonitis. By Herbert P. Hawkins, IM.A., M.D., F.R.C.P. 8vo. Cloth 

pp. 139. $2.25, net. 

HILTON (J.)- —Rest and Pain. Edited by W. H. A. Jacobson. $2.00. 

HOBLYN. — Dictionary of Medical Terms. Twelfth Edition. S2.25. 

HULL AH (J.). — The Cultivation of the Speaking Voice. Clarendon 
Press Series. Second Edition. i6mo. 60 cents. 

HUXLEY (T. H.). — Lessons in Elementary Physiology. With numerous 

Illustrations. Revised by Dr. Foster. i6mo. $1.10. 

"Unquestionably the clearest and most complete elementary treatise on this subject that we 
possess in any language. In this admirable little work, the outlines of the physiology of the human 
body are set forth in the plainest English, with a simplicity and earnestness of purpose which com- 
mand our highest admiration." — Westminster Revieiu. 

JENNER (Sir William). — Lectures and Essays on Fevers and Diphtheria, 
1819-1879. 8vo. $4.00. 

" This volume is a fitting exemplar of the careful and scientific work that has placed the author 
in the foremost rank of his profession. It cannot fail to prove interesting to physicians." — Neiv 
York Medical Journal. 

Clinical Lectures and Essays on Rickets, Tuberculosis, Abdominal 
Tumours, and Other Subjects. 8\o. 34.00. 

JEX-BLAKE (Sophia). — The Care of Infants. iSmo. 40 cents. 

KANTHACK (A. A.). — A Course of Elementary Practical Bacteriology, 
including Bacteriological Analysis and Chemistry. By A. A. Kan- 
THACK, Lecturer on Pathology and Bacteriology, St. Bartholomew's Hospital, 
and J. H. Drysdale. i2mo. Cloth. $1.10. 

KIMBER. — Text-book of Anatomy and Physiology for Nurses. Com- 
piled by Diana Clifford Kimber, graduate of Belleviie Training School ; 
Assistant Superintendent New York City Training School, Black well's Island, 
N. Y.; formerly Assistant Superintendent Illinois Training School, Chicago, 111. 
Fully Illustrated. 8vo. $2.50, 

" A well written and unusually thorough work for its purpose. Although intended for nurses, it 
would make an admirable text-book in our schools and academies." — Afiierican Medico-Surgical 
Bulletin. 



WORKS ON THE MEDICAL SCIENCES. 



KLEIN (E.)— Micro-organisms and Disease. Revised, with 120 Engrav- 
ings. $1.00. 

The Bacteria in Asiatic Cholera. $1.25. 

KOCHER. —Text-Book of Operative Surgery. By Dr. Theodor Kocher, 
Professor of Surgery and Director of the Surgical Clinic in the University of 
Bern. Translated with the Special Authority of the Author from the Second 
Revised and Enlarged German Edition by Harold J. Stiles, M.B., F.R.C.S., 
Edin., Senior Demonstrator of Surgery and formerly Demonstrator of Anatomy 
in the University of Edinburgh, etc. With 185 Illustrations. 8vo. ^^3.50. 

MACALISTER. — A Text-Book of Physical Anthropology. /« press. 

MACDONALD (GRE^'rt.T.E) —A Treatise on Diseases of the Nose and 
its Accessory Cavities. Second Edition. 8vo. $2.50. 

MACEWEN. — Pyogenic Infective Diseases of the Brain and Spinal 
Cord, Meningitis, Abscess of Brain, Infective Sinus Thrombosis. 

By William Mackvvkn, M.D., Glasgow. 8vo. Buckram. $6.00. 

Atlas of Head Sections. 53 Engraved Copperplates of Frozen Sections of 
the Head, and 53 Key Plates with Descriptive Tests. Folio. Bound in 
buckram. ^21.00. 

" The ' Atlas ' should certainly be in the hands of every surgeon who aspires to enter the field of 
brain surgery, as a careful inspection of these plates will teach more than many volumes written upon 
the subject. . . . The plates themselves have been executed with the greatest care, the illustrations 
being very fine photogravures from photographic plates, about two-thirds of the actual size of the 
head. The appearance of the book is a credit both to the author and to the publisher." — Medical 
Record. 

M'KENDRICK (J. G.). — A Text-book of Physiology. In 2 volumes. 
Vol. I. General Physiology. 8vo. $4.00. 
Vol. II. Special Physiology. 8vo. ^6.00. 
Life in Motion ; or. Muscle and Nerve. Illustrated. $1.50. 

MACLAGAN (T.). — The Germ Theory. 8vo. ^3.00. 

MACLAREN (Archibald). — A System of Physical Education. With 
Illustrations. Clarendon Press Series. i6mo. ^1.75. 

MACLEAN (W. C.). — Diseases of Tropical Climates. ^3.00. 

MARSHALL. — Pain, Pleasure, and -Esthetics. By Henry Rutgers Mar- 
shall. 8vo. ^3.00. 

" The book must necessarily have a deep interest for physicians, and especially neurologists, for 
it is concerned largely with the explanation of a phenomenon — pain, the prevention and relief of 
which form such a good portion of their duty. We can heartily recommend it to their perusal and 
study." — Journal of Nervous and Mental Disease. 

MAUDSLEY. — The Pathology of Mind : A Study of its Distempers, 
Deformities, and Disorders. Second Edition. By Henry Maudsley, 
M.D. 8vo. Cloth, pp. 571. ^5.00, 7iet. 

MERCIBR (C). — The Nervous System and the Mind. 8vo. 1^4.00. 

MIERS (H. A.) and CROOSKEY (R.). — The Soil in Relation to Health. 
By Henry A. Miers and Roger Crouskev. $1.10. 

MIGITLA (W.). — An Introduction to Practical Bacteriology. Translated 

by M. Campbell, and edited by H. J. Campbell, M.D. Illustrated. $1.60. 

" Its practical character fits it for a guide for students desiring a knowledge of the elementary 
principles of this iiUCiesting and important topic." — Popular Science Monthly. 



AND CONNECTED SUBJECTS. 



MIVART (St. George). — Lessons in Elementary Anatomy. With 400 

Illustrations. i6mo. $1.75. 

PALMBERG (A.). — A Treatise on Public Health, and its Application in 
Different European Countries (England, France, Belgium, Germany, 
Austria, Sweden, and Finland). Edited by Arthur Newsholme. 8vo. 
^5.00. 

" The book is rich in descriptions and illustrations of sanitary appliances, modern and practical." 
— Popidar Science Monthly. 

PIFFARD (H. G.). — An Elementary Treatise on Diseases of the Skin. 

With Illustrations. 8vo. $4.00. 

PRACTITIONER (The). — A Monthly Journal of Therapeutics and 
Public Health. Edited by T. Lauder Brunton, M.D., F.R.S., and Don- 
ald Macallister, M.A., M.D. Price, 35 cents, monthly. Annual Sub- 
scription, $3.50. 

Vols. I.-XLII. Half-yearly vols. $2.50. 

Cloth covers for binding volumes, 40 cents. 

REYNOLDS. —A Primer of Hygiene. By Ernest S. Reynolds, M.D. 
(Lond.), Senior Physician to the Ancoats Hospital, INIanchester, etc., etc. 
W^th 50 Illustrations. i8mo. 35 cents. 

" This is a rare bit of text-book making. The pedagogical features are eminently creditable ; the 
literary work, from the text-book standpoint, is admirable. The illustrations are simple, but ideal in 
their clearness and illustrative qualities." — Journal of Education. 

RICHARDSON. — Works by B. W. Richardson, M.D. 
On Alcohol. Paper, 30 cents. 
Diseases of Modern Life. New Edition. (/// the Press.) 

ROLLESTON and KANTHACK. —Manual of Practical Morbid Anat- 
omy. Being a Hand-book for the Post-mortem Room. Cambridge N'atiiral 
Science Manuals : Biological Series. i2mo. $1.60. 

" To those interested in post-mortem work, this book can be heartily recommended as a most 
valuable, complete, and efficient guide." — American Medico-Surgical BTtlletin. 

STEVEN (J. L.). —Practical Pathology. $1.75. 

STRAHAN. — Suicide and Insanity. A Physiological and Sociological Study. 
By S. A. K. Strahan, IM.D., Author of " Marriage and Disease," " Instinctive 
Criminality," etc. i2mo, cloth. ^1.75. 

" The subject treated of in Dr. Strahan's excellent little work has always possessed, and, in the 
nature of things, must in future possess keen interest, not only for physicians and jurists, moralists, 
and sociologists, but for all thinking persons. That such a fundamental instinct as the desire to live 
should ever so far yield, either to reason or imperative craving, as to culminate in self-destruction, is 
a phenomenon so opposed to the principles of animal existence as to afiect even the most unimagina- 
tive very much as would the sudden reversal of the law of gravitation." — Medical Record. 

" The book is a most interesting contribution to the literature of a subject that is of increasing 
interest to the alienist and psychologist." — JST. V. Medical Jonrnnl. 

" The author has presented a very interesting and unbiased study of a topic that is engaging more 
and more attention, for it is not one of the least of the charges against modern society that its organi- 
zation is such that men and women are unwilling to continue as associates thereof." — Popular 
Science Monthly. 

THORNE. — Diphtheria. Its Natural History and Prevention. By R. Thorne. 

$2.00. 



WORKS ON THE MEDICAL SCIENCES. 



VON KAHLDEN. — Methods of Pathological Histology. By C. von 

Kahlden, Assistant Professor of Pathology in the University of Freiburg. 

Translated and Edited by H. Morley Fletcher, M.D., Casualty Physician to 

St. Bartholomew's Hospital, and Assistant Demonstrator of Physiology in the 

Medical School. With introduction by G. Sims Woodhead, M.D,, Director of 

the Laboratories of the Royal Colleges of Physicians and Surgeons, etc. ^1.40. 

"This manual of methods recommends itself to every student of histological research. In the 
form of footnotes are presented additions and modifications of great practical value, which bring the 
book up to date. There are chapters on the microscope and apparatus requisite for histological work, 
examination of fresh tissues, methods of hardening, decalcification of tissues, methods of embedding, 
infection of tissues, preparing and mounting sections, staining processes, bacteria, moulds, fungi, 
animal parasites, and microscopical examinations for medico-legal purposes." — Medical Summary. 

WHITE (W. Hale, M.D.). — A Text-book of General Therapeutics. $2.50. 

" In no other text-book of Therapeutics can the same interesting, varied, and necessary material 
be found so usefully, successfully, and agreeably presented." — N. E. Medical Monthly. 

WILLIAMS. — Aero-Therapeutics. The Treatment of Lung Diseases by 

Climate. Being the Lumleian Lectures for 1893 delivered before the Royal 

College of Physicians. With an address on the high altitudes of Colorado. 

By Charles Theodore Williams, M.D., Senior Physician to the Hospital 

for Consumption and Diseases of the Chest, Brompton, and late President of 

the Royal Meteorological Society. 8vo, cloth. ^2.00. 

" It is not an exhaustive work, it is true, but it is sufficiently full for the practitioner's needs, 
accurate, practical, and charmingly written. For those who wish a small work on the climatic treat- 
ment of pulmonary diseases, written by a recognized authority on the subject, and presenting practi- 
cally and usefully most reliable information on a very important subject, we must heartily recommend 
Dr. Williams's work." — N. Y. Medical Journal. 

WILLOUGHBY (E. F.). —Handbook of Public Health and Demography. 

i6mo. ^1.50. 

"An admirably concise and lucid treatment of preventive medicine, alike commendable to general 
readers, teachers, students, physicians, and sanitary inspectors." — The Sanitarian. 

ZIEGLER. — A Text-book of Pathological Anatomy and Pathogenesis. 

With Illustrations. 8vo, 
Part I. Special Pathological Anatomy. Sections I.-VIII. ^4.00. 
Part II. Special Pathological Anatomy. Sections IX.-XII. In prepa- 
ration. 
Part III. General Pathological Anatomy. In preparatiojt. 

ZIEHEN (Theodore). — Introduction to Physiological Psychology. 

Translated by C. C. Van Liew and Dr. Otto Beyer. With 21 Illustrations. 
^1.50. 
" The book can be highly recommended to all who wish a short and clear outline of the science." 
— Educational Review. 

" The general reading of this book would, we think, do more for the schools of America than the 
investment of the same amount of time and money in anything else." — Journal of Education. 



THE MACMILLAN COMPANY. 

NEW YORK: 66 FIFTH AVENUE. 
CHICAGO! EOOM 23, AUDITORIUM. 



